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

McCarthy et al

Adult

The relationship of atrial fibrillation and tricuspid annular dilation to late tricuspid regurgitation in patients with degenerative mitral repair Patrick M. McCarthy, MD,a Michal Szlapka, MD,a Jane Kruse, BSN,a Olga N. Kislitsina, MD,a James D. Thomas, MD,b Menghan Liu, MS,a Adin-Cristian Andrei, PhD,c and James L. Cox, MDa ABSTRACT

Risk and impact of late tricuspid valve regurgitation in patients after degenerative mitral valve surgery Tricuspid annular dimensions ≥ 45 mm increased the risk of late tricuspid regurgitation, but not 40-44 mm.

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 ¼ .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 ¼ .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. (J Thorac Cardiovasc Surg 2019;-:1-11)

TAD ≥ 45mm 40%

Model

TAD Group

HR (95% CI)

P-value

Unadjusted

< 40mm 40-44mm ≥ 45mm

REF 0.92 (0.53, 1.59) 2.47 (1.34, 4.57)

REF .76 .004

Adjusted

< 40mm 40-44mm ≥ 45mm

REF 0.63 (0.32, 1.28) 3.25 (1.54, 6.87)

REF .20 .002

HR (95% CI)

P-value

TAD < 40mm 20% TAD 40 – 44mm 0% 0

2

423 89 27

354 70 16

4 Years Since Surgery 246 49 11

6

8

158 26 9

79 14 8

Preoperative atrial fibrillation, even though treated in 97% of patients, was associated with an increased risk of late tricuspid regurgitation.

50% Preop AFib

40% 30%

Model

20%

Group

Unadjusted

No Preop AFib

Adjusted

No Preop AFib

No Preop AFib

Preop AFib

10%

Preop AFib

REF

REF

2.84 (2.07, 3.89)

< .001

REF

REF

2.25 (1.52, 3.32)

< .001

0% 0

2

591 178

517 132

4 Years Since Surgery 395 97

6

8

298 66

216 44

Late ≥ moderate tricuspid valve regurgitation was associated with increased late mortality: unadjusted HR 3.58 (2.04, 6.29), P-value < .001; adjusted HR 2.37 (1.23, 4.57), P-value = .010

Risk factors for late TR after surgery for DMR.

CENTRAL MESSAGE

In patients with DMR undergoing mitral surgery with less than moderate TR preoperatively, TV annular diameter 45 mm or more and AF (despite ablation in 97%) were associated with late moderate or more TR.

ADULT

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%).

60%

60%

Probability of TR ≥ Moderate

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.

Probability of TR ≥ Moderate

80%

PERSPECTIVE In patients with DMR with less than moderate TR, TV annular diameter of 45 mm or more was associated with late TR, and TVA should be considered in these patients. Preoperative AF, despite AF ablation surgery in 97%, also predicted a greater risk of late TR, and TVA may be considered in these patients. Patients with late TR had a higher late mortality. See Commentary on page XXX.

Patients with degenerative mitral regurgitation (DMR) are also commonly found to have atrial fibrillation (AF) and tricuspid annular dilation (TAD) with tricuspid regurgitation (TR). The current valve guidelines suggest

that patients undergoing left-side valve surgery should undergo tricuspid valve annuloplasty (TVA) in the presence of severe TR. For patients with mild or moderate TR, there is a Class IIa recommendation to add TVA in the presence of

From the aDivision of Cardiac Surgery, Department of Surgery and bDivision of Cardiology, Department of Medicine, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Ill; and cDivision of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Ill. Institutional Review Board Approval: Northwestern University STU00012288. Read at the 99th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, May 4-7, 2019.

Received for publication May 7, 2019; revisions received Nov 12, 2019; accepted for publication Nov 13, 2019. Address for reprints: Patrick M. McCarthy, MD, Division of Cardiac Surgery, Northwestern University, 201 East Huron St, Suite 11-140, Chicago, IL 60611-2908 (E-mail: [email protected]). 0022-5223/$36.00 Copyright Ó 2019 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2019.11.098

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Abbreviations and Acronyms AF ¼ atrial fibrillation DMR ¼ degenerative mitral regurgitation HR ¼ hazard ratio MR ¼ mitral regurgitation MV ¼ mitral valve PS ¼ propensity score RV ¼ right ventricle TAD ¼ tricuspid annular dilation TR ¼ tricuspid regurgitation TVA ¼ tricuspid valve annuloplasty

Scanning this QR code will take you to the article title page to access supplementary information. To view the AATS Annual Meeting Webcast, see the URL next to the webcast thumbnail.

ADULT

TAD if it is 40 mm or greater on 2-dimensional echocardiography.1,2 In our center, TVA is routinely added for patients with moderate or more TR. For patients with less than moderate TR, it is unusual to add TVA unless there is a history of right heart failure symptoms. The complexity of the relationship of AF to late TR has had sparse investigation in the surgical literature.3-5 There has been increasing recognition that AF is associated with annular dilation and functional TR and mitral regurgitation (MR), and this has been referred to as ‘‘atrial functional MR and TR.’’6,7 Reports have suggested that successful AF ablation surgery will prevent the late development of TR.3-5 AF ablation for concomitant mitral valve (MV) surgery is now a class I indication, but it is unclear if that will affect the development of late TR.8 Furthermore, if AF itself can cause late TR by way of atrial functional TR, then perhaps TVA should be added to MV surgery in patients with AF and less than moderate TR, just as it is a guideline consideration for patients with TAD. Therefore, in patients with DMR undergoing surgery with less than moderate TR, we sought to determine (1) the incidence of preoperative AF and TAD; (2) the association of each with late TR; and (3) the degree of TAD associated with late TR. MATERIALS AND METHODS Patients and Study Design This study is a single-institution, multi-surgeon review of consecutive patients undergoing surgical MV repair for type II degenerative disease. Preoperative, intraoperative, and postoperative data were obtained from the Cardiovascular Research Database in the Clinical Trials Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital

2

(Institutional Review Board at Northwestern University STU00012288) and medical record review. Patients who refused participation in the registry were excluded. Patients who underwent first-time nonemergency DMR surgery with or without other cardiac surgery between April 19, 2004, and June 30, 2017, were included. Other MR etiologies, or ‘‘mixed’’ lesions with DMR and other etiologies together, were excluded. Patients underwent routine intraoperative and predischarge echocardiograms, and received surveys at 3, 6, and 12 months after surgery and annually thereafter to report quality of life surveys, medical visits, and additional echocardiograms performed at the judgment of the cardiologist. In patients who underwent AF surgery, rhythm monitoring with mobile cardiac outpatient telemetry or 30-day event monitors was recommended at 3, 6, and 12 months and annually, performed at the discretion of the cardiologist who was provided a follow-up protocol. Telephone follow-up was performed by the AF nurses within the first month and again at 3, 6, and 12 months and annually to assist with obtaining monitors. Medical records were obtained to verify operations, echocardiogram reports, or hospitalizations. In the follow-up studies, readings of intermediate grades of TR were upgraded so that trivial to mild regurgitation was in the mild (1þ) TR group and mild to moderate regurgitation was in the moderate (2þ) group. Moderate to severe regurgitation was graded 3þ, and severe regurgitation was graded 4þ. The Society of Thoracic Surgery definitions were used to determine perioperative complications. Mortality data were aggregated continuously consulting sources that included (1) Cardiovascular Research Database registry; (2) reviews of medical records and correspondence with the treating physician; (3) online death searches and genealogy resources (ancestry.com); and (4) newspaper death notices. Mean follow-up was 6.7  3.8 years (range, 0.01-14.8 years). Patients were grouped by preoperative AF status (no AF and AF group), and characteristics were compared. Subanalysis was performed on patients who underwent TVA and separately on those who did not have TVA. Risk profile, preoperative and intraoperative characteristics, and postoperative results were compared retrospectively. Freedom from recurrent, moderate, or greater TR in late follow-up constituted the primary study end point. Consolidated Standards of Reporting Trials flow diagrams were created to detailed cohort structure in the follow-up.

Echocardiographic Measurement of Tricuspid Annular Dimension Preoperative transthoracic echocardiography, including 2-dimensional echocardiographic and Doppler color flow examinations, was performed in all patients. Progression of MR was defined as worsening of MR by integrative MR severity grading system (jet MR area, vena contracta, regurgitant fraction, effective regurgitant orifice) and graded as mild, moderate, moderate to severe, or severe. The image settings were set for optimal visualization of the TV by adjusting the gain, depth, compression, and time gain. TR was evaluated by Doppler color flow mapping images of the regurgitant jet and pulsed-wave Doppler evidence of systolic flow reversal in the inferior vena cava or hepatic veins. The severity of TR was graded as follows: none, mild, moderate, and severe.1 The TV annulus was viewed in the right ventricle (RV) inflow, apical 4-chamber, and apical RV-focused views. TV annulus diameter was measured in end diastole at the level of the hinge points of the opposing TV leaflets, as defined by the frame preceding TV closure. In the early days of the study, TV annulus diameter was not routinely recorded. In addition, the apical RV focused views essential for TV measurements were often not performed. In those patients (N ¼ 212) who did not have proper views of the TV, the quality of the pictures was often too poor to be useful for tricuspid annulus measurements.

Surgical Procedures MV repair was the preferred surgical strategy. For elderly patients with extensive leaflet calcification, chord-sparing MV replacement technique

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CONSORT Diagram for Tricuspid Annulus Diameter Information

CONSORT Diagram for Preoperative Atrial Fibrillation Information

Mitral valve surgery for degenerative mitral regurgitation (n = 1079)

Mitral valve surgery for degenerative mitral regurgitation (n = 1079) Refused participation (n = 58)

Included for analysis (n = 1021)

Included for analysis (n = 1021)

None/trivial or mild preoperative tricuspid regurgitation (n = 869)

None/trivial or mild preoperative tricuspid regurgitation (n = 869)

Tricuspid annulus measured (n = 657)

Preoperative atrial fibrillation (n = 199)

Follow-up echo (n = 569)

Ablation (n = 194)

A

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Refused participation (n = 58)

B

FIGURE 1. Consolidated Standards of Reporting Trials diagrams detailing sample size available for follow-up analyses by tricuspid annulus diameter (A) and AF (B). was performed. Concomitant TVA with an annuloplasty ring was performed when there was a clinical history of right heart failure. AF ablation was performed with the use of bipolar radiofrequency clamps, cryoablation, or ‘‘cut and sew.’’

Late Follow-up Information Consolidated Standards of Reporting Trials diagrams in Figure 1, A and B, describe sample sizes available for analyses by tricuspid annulus diameter and AF status.

Statistical Analyses Variables with a continuous distribution were summarized using mean  standard deviation or median (first/third quartiles Q1/Q3). Categoric variables were presented as counts and percentages. Group comparisons involving continuously distributed variables were based on the 2-sample t test with Satterthwaite’s approximation or Wilcoxon rank-sum test. When comparing categoric variables, we used chi-square or Fisher exact tests (cell counts <5). TR progression comparisons by preoperative AF status were based on propensity score (PS)-matched groups. We modeled the probability of preoperative AF using a logistic regression model that adjusts for the following variables: age, gender, body surface area and mass index, SMD2 score, left ventricular ejection fraction, creatinine level, comorbidities (diabetes, hypercholesterolemia, hypertension, chronic obstructive pulmonary disease, cerebrovascular disease, prior myocardial infarction, prior congestive heart failure, TV insufficiency), NYHA class III or IV, repeat sternotomy, surgical procedures (coronary artery bypass grafting, aortic valve surgery, MV repair or replacement),

and TV annular diameter class. PS matching in 1-to-(up to)-3 ratio between patients with or without preoperative AF was achieved on the basis of a Greedy algorithm using a caliper of size 0.1 logit-PS standard deviation units. Baseline covariate balance was evaluated using standardized mean differences and considered adequate if less than 0.2 in absolute value. Probability of late TR moderate or greater was estimated using cumulative incidence functions, in the presence of mortality as a semi-competing risk. Unadjusted and adjusted group comparisons for risk of TR progression by preoperative AF status and by preoperative TV annular diameter were based on the Fine-Gray model. Corresponding summaries included hazard ratios (HRs) and 95% confidence intervals. Additionally, because more than 1 TR evaluation might have been observed for some patients, late moderate or greater TR (as a binary outcome) was analyzed using generalized linear modeling, and odds ratios were obtained using generalized estimating equations under a working independence within-individual correlation structure. To evaluate whether or not progression to TR moderate or higher in late follow-up is associated with long-term outcomes, we created unadjusted and covariate-adjusted Cox regression models in which time to TR progression was treated as a time-dependent covariate. In all adjusted models, adjustments were made for the preoperative AF status and the explanatory variables in the PS model. Statistical analyses were performed in R 3.4.2 (R Development Core Team (2017) or SAS 9.4 software (SAS Institute Inc, Cary, NC).

RESULTS A total of 1021 patients with DMR underwent elective MV surgery. Of these, 869 (85%) had less than moderate

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TABLE 1. Preoperative characteristics of patients with less than moderate tricuspid regurgitation on preoperative echocardiography N

Entire cohort (N ¼ 869)

Age (y)

869

59.3  12.1

Female

869

265 (30)

Tricuspid annulus size

657

35.4  6.1

Tricuspid annulus >40 mm

657

494 (75)

Tricuspid annulus 40-45 mm

657

112 (17)

Tricuspid annulus >45 mm

657

51 (8)

Left atrial volume index

678

51.9  22.3

Ejection fraction, median

863

60.0 (57.0, 65.0)

New York Heart Association Class III/IV

868

111 (13)

Congestive heart failure

869

126 (14)

Tricuspid insufficiency 0 ¼ none/trivial 1 ¼ mild

869

Variable

526 (61) 343 (39)

Values are mean  standard deviation; n (%); or median (first quartile, third quartile).

ADULT

TR on preoperative echocardiogram and 846 (97.3%) received MV repair. These patients are the focus of this study (Table 1). Preoperative AF was present in 199 patients, and AF ablation surgery was performed in 194 patients (97.5%). Left atrial appendage exclusion was performed in 184 (95%) of the ablation surgeries. TVA was performed in 31 of 869 (3.6%) of the ablation surgeries. A total of 657 patients had preoperative echocardiograms that allowed accurate measurement of TAD. In current practice of early referral for mitral surgery in patients with DMR, 87% had New York Heart Association functional class I or II. There were minor differences in baseline characteristics between patients with and without echocardiographic information in late follow-up, suggesting a reduced potential for selection bias (Table E1). Echocardiography in late follow-up was performed at Northwestern in 40% of the patients. The mean interval between the index operation and the follow-up echocardiography was 4.0  3.3 years. As would be expected, the patients with AF were older and had more comorbidities, such as hypertension, chronic lung disease, congestive heart failure, and prior myocardial infarction (Table 2). AF type was paroxysmal in 69%, and the mean AF duration was 2.7  4.5 years. Their operations were longer and more complex, and 11% with AF had TVA versus 1.4% without AF (P <.001). Of the 657 patients with TAD available (Table 3), most (75.2%) had an annulus less than 4.0 cm (mean 32.8  4.3 mm); 17% were between 40 and 44 mm (41.1  1.2 mm) and 7.8% were 45 mm or more (47.8  3.1 mm). Patients with a more dilated annulus 4

were older and had a more dilated left atrium and pulmonary hypertension. AF duration was similar, but these patients had more long-standing persistent AF. These operations were also longer and more complex (Table 3). TVA was performed in zero patients with an annulus less than 40 mm, in 8% (9/112) with an annulus 40 to 44 mm, and in 43% (22/51) with an annulus 45 mm or more (P <.001). In the patients who did not undergo TVA and with a TAD less than 40 mm, and for those with no AF, there was little development of late TR (Figures 2 and 3). Because the American Heart Association and European Society of Cardiology guidelines suggest consideration of TVA for TAD 40 mm or more, it was surprising to see no significant increase in late TR in the 40- to 44-mm group (Figure 2) (adjusted HR, 0.63, P ¼ .20). However, for the more dilated TVannulus, 45 mm or more, there was a significant increase in late TR (adjusted HR, 3.25; P ¼ .002). In the original groups, patients with AF showed a significant increase in the development of late TR compared with those with no AF (Figure 3, A; HR, 2.25; P <.001). This increase in TR increased steadily over time. This is despite 97% of patients with AF having had an AF ablation procedure, and 80.1% (4.8  3.4 years follow-up) were free from AF off antiarrhythmic drugs at last follow-up. In expanded multivariable analyses further adjusting for AF duration, LA size and volume, and type of AF ablation, the type of AF was not significantly associated with late TR, but the duration of AF was (HR, 1.11 [1.03-1.19], P ¼ .004). Larger left atrial size was associated with less late TR (HR, 0.51 [0.30-0.87], P ¼ .013). The type of AF ablation procedure, LA only versus biatrial (HR, 0.73 [0.28-1.95], P ¼ .54), and LA volume (HR 1.00 [0.99-1.01], P ¼ .73) did not correlate with late TR. PS matching resulted in well-balanced baseline characteristics, as shown by the standardized mean differences in Figure E1. In the PS-matched groups, patients with AF showed a significant increase in the development of late TR compared with those with no AF (Figure 3, B; HR, 2.69, P < .001). In a similarly expanded multivariable analysis, the type of AF was not significantly associated with late TR, but the AF duration was (HR, 1.11 [1.01-1.20], P ¼ .022). Larger left atrial size (HR, 0.67 [0.28-1.60], P ¼ .37), AF ablation procedure type, LA only versus biatrial (HR, 0.70 [0.21-2.30], P ¼ .56), and LA volume (HR, 1.00 [0.99-1.01], P ¼ .75) did not correlate significantly with late TR. Generalized estimating equations–based unadjusted odds ratio for moderate or greater TR was 6.6 (95% confidence interval, 2.7-16.3; P < .001) when comparing patients with preoperative AF with those without preoperative AF (reference). Progression to moderate or higher TR was associated with an increase in long-term mortality: unadjusted HR

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TABLE 2. Preoperative and intraoperative characteristics of patients with and without atrial fibrillation Variable

N

No preoperative AF (N ¼ 670)

Preoperative AF (N ¼ 199)

P value

Age (y)

869

57.8  11.9

64.3  11.4

<.001

CHA2DS2-VASc

869

1.4  1.2

2.1  1.5

<.001

Hypertension

869

314 (47)

Chronic lung disease

867

27 (4)

17 (9)

Congestive heart failure

869

75 (11%)

51 (26)

Previous myocardial infarction

864

12 (2)

12 (6)

Tricuspid annulus dimension, mm

657

Tricuspid annulus 40

657

33.8  5.4 69 (14)

117 (59)

39.8  5.8 94 (53)

.003 .011 <.001 .001 <.001 <.001

Tricuspid annulus 45

657

Ejection fraction

863

61.0 (60.0, 65.0)

60.0 (55.0, 65.0)

<.001

Left atrial volume index

678

48.9  19.9

60.8  26.3

<.001

Left atrial size (cm)

749

4.3  0.7

4.6  0.8

<.001

16 (3)

35 (20)

<.001

2.7  4.5

AF duration (y) AF type Paroxysmal Persistent Long-standing persistent

194

AF surgery Biatrial Classic cut and sew Left only

194

TVA

869

10 (1)

21 (11)

MV repair

869

655 (98)

191 (96)

.17

Aortic valve surgery

869

18 (3)

18 (9)

<.001

ADULT

134 (69) 25 (13) 35 (18) 35 (18) 11 (6) 148 (76)

30-d mortality

869

Freedom from AF, off antiarrhythmic drugs

171

3 (0.4)

1 (0.5)

<.001

.92

137 (80.1)

Values are mean  standard deviation; n (%); or median (first quartile, third quartile). AF, Atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age, diabetes, stroke, vascular disease; TVA, tricuspid valve annuloplasty; MV, mitral valve.

3.58 (2.04-6.29; P < .001); adjusted HR 2.37 (1.23-4.57; P ¼ .010). DISCUSSION Our study found some similarities to prior publications and several differences. The frequency of preoperative AF was lower than in other reports and less than the 39% we have reported in our patients with mitral disease many years ago.9 We believe this reflects the current practice to refer patients for early DMR repair consistent with the latest guidelines.1 We have generally been conservative regarding the use of TVA for patients with less than moderate TR and a dilated TVannulus as the only indication for TVA. Despite the guidelines suggesting this should be considered for patients with a TAD of 40 mm or more, we found no significant increase in late TR until the TAD reached 45 mm. We did add TVA to 8% in the 40- to 44-mm group and 43% of those in the 45 mm or greater group, most commonly due to a preexisting history consistent with right

heart failure. Reports suggested that performing AF ablation may be associated with the reduction of late TR, but we did not find this despite ablation surgery in 97% of our patients with AF (Figure 4).3-5 The guidelines recommendation of TAD and annulus size is based on a small number of studies with a small number of patients. Dreyfus and colleagues10 published a series of 311 patients, some treated with and some without TVA, and the determination was based on direct measurement of the largest TAD. His determination was based on a measurement of 70 mm, which is larger than the guidelines suggestion of 40 mm. We routinely measure the TAD in our patients with DMR undergoing transcatheter aortic valve and rarely measure one more than 55 mm. Again, this may reflect the current practice of early referral before pulmonary hypertension, right ventricular dilation, and TAD have developed. Dreyfus and colleagues’10 series was between 1989 and 2001 and may reflect the practices of that time, not the early referrals we see today. Another

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TABLE 3. Characteristics of 657 patients with tricuspid annular dimensions available Variable Age (y) CHADS2-VASC Pulmonary hypertension

TAD <40 mm (N ¼ 494)

TAD (40 mm, 44 mm) (N ¼ 112)

TAD 45 mm (N ¼ 51)

59.4  11.7

61.4  11.7

64.7  10.9

.004

1.9  0.2

2.1  0.2

2.1  0.3

<.001

153 (43)

35 (43)

28 (65)

P value

.018

Chronic lung disease

20 (4)

8 (7)

3 (6)

.35

Congestive heart failure

65 (13)

21 (19)

11 (22)

.12

Previous myocardial infarction

10 (2)

8 (7)

2 (4)

.016

Tricuspid annulus dimension, mm Ejection fraction

32.8  4.3

41.1  1.2

47.8  3.1

62.0 (60.0, 65.0)

60.0 (55.0, 65.0)

60.0 (55.0, 65.0)

49.0  19.7

58.8  27.5

68.4  29.2

Left atrial size (cm)

4.4  0.8

4.3  0.7

4.6  0.8

AF duration (y)

2.7  5.1

2.5  3.6

3.2  4.7

Left atrial volume index

ADULT

AF type Paroxysmal Persistent Long-standing persistent

62 (76) 8 (10) 12 (15)

38 (66) 10 (17) 10 (17)

16 (48) 7 (21) 10 (30)

AF surgery Biatrial Classic cut and sew Left only

12 (15) 4 (5) 65 (80)

11 (19) 5 (9) 42 (72)

11 (33) 2 (6) 20 (60)

TVA MV repair Aortic valve surgery 30-d mortality

<.001 .002 <.001 4.7 .76 .045

.08

0 (0)

9 (8)

22 (43)

<.001

479 (97)

109 (97)

49 (96)

.91

16 (3)

7 (6)

6 (12)

.011

2 (0)

0 (0)

0 (0)

.72

Values are mean  standard deviation; n (%); or median (first quartile, third quartile). TAD, Tricuspid annular dilation; CHA2DS2-VASc, congestive heart failure, hypertension, age, diabetes, stroke, vascular disease; AF, atrial fibrillation; TVA, tricuspid valve annuloplasty; MV, mitral valve.

article used to support TAD compared a cohort with both organic and functional MV disease in 80 patients treated in 2002 with another cohort (N ¼ 102 patients) from 2004.11 Outcomes were reported in 2 groups: less than 40 mm and 40 mm or more. In those with 40 mm or more who did not receive TVA, there was a progression in TR and right ventricular dilation. It is important to note that the 2002 group included 29% of patients with functional MR, and in 2004 that had increased to 50%. Cardiomyopathy is known to progress and is associated with late TR, and including these patients with DMR should be interpreted with caution.12,13 The possible relationship of recurrent MR contributing to late moderate or more TR is an intractable statistical problem due to the competing risks of death, recurrent MR, and recurrent TR. However, our recent publication of DMR repair in 1155 patients documented that only 7% developed moderate or more MR during 10 years of follow-up, indicating this should not be a major contributing factor. Recent investigations have shown the association of AF with structural rearrangements including left or right atrial 6

remodeling, mitral and TAD, and eventually valve regurgitation.14-17 In patients with AF-related MR, restoration of sinus rhythm through ablation may be associated with a reversal of these unfavorable changes and with an obviation of the need for surgical valve repair, but these are patients with atrial functional MR, not DMR.14 Others have advocated adding AF ablation with mitral surgery to protect patients with DMR with less than moderate TR against TR progression. According to some investigators, restoration of sinus rhythm was associated with prevention of TR progression in these patients, without the need for concomitant tricuspid valve repair.3-5 Although that was true for most of our patients, preoperative AF, in our series, was a more important risk factor for late TR than an enlarged tricuspid annulus. Of note, the Mayo article reported on 33 patients with preoperative AF who underwent the combined Maze procedure and MV operation who converted to sinus rhythm postoperatively and remained in sinus rhythm through last follow-up.3 The comparison group consisted of patients with AF preoperatively who underwent MV surgery alone and remained in AF postoperatively and through last

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60% TAD ≥ 45mm 40%

Model

TAD Group

HR (95% CI)

P-value

Unadjusted

< 40mm 40-44mm ≥ 45mm

REF 0.92 (0.53, 1.59) 2.47 (1.34, 4.57)

REF .76 .004

Adjusted

< 40mm 40-44mm ≥ 45mm

REF 0.63 (0.32, 1.28) 3.25 (1.54, 6.87)

REF .20 .002

TAD < 40mm 20% TAD 40 – 44mm 0%

0

2

423 89 27

354 70 16

4 Years Since Surgery 246 49 11

6

8

158 26 9

79 14 8

FIGURE 2. Time-evolving probability of late moderate or greater TR by TAD among patients who did not receive TVA. TR development probabilities estimated over time were lower among patients with TAD less than 40 mm or 40 to 45 mm compared with the group with TAD greater than 45 mm. Unadjusted and covariate-adjusted HRs for the TAD group, together with 95% confidence intervals, are presented. TR, Tricuspid regurgitation; TAD, tricuspid regurgitation; HR, hazard ratio; CI, confidence interval.

follow-up. This approach is susceptible to selection bias because it provided results only for those who had the best outcome from the AF ablation and not those who had no AF intervention and remained in AF. Postoperative AF is a moving target, and its associations with other postoperative events remain difficult or impossible to analyze statistically. Late freedom from AF, as documented according to Heart Rhythm Society guidelines, was high in our treated patients with AF (80.1%), but one can speculate that the patients who failed ablation were more prone to late TR. ‘‘Failure’’ includes a wide variety of patients: Some may have a single episode of AF more than 30 seconds, others may have a significant burden of paroxysmal AF, and others may have completely failed and redeveloped long-standing persistent AF.18 All of those may be asymptomatic. That methodologic shortcoming is compounded because there are inadequate methods to reliably detect AF (except patients with a permanent pacemaker and an atrial lead). Furthermore, we have reported on our patients without preoperative AF that by 10 years after surgery 24% develop de novo, new-onset, AF.19 Comparison between the AF treated and no AF groups is difficult because AF may be paroxysmal, asymptomatic, and not detected. Therefore, we have hard data that AF is present preoperatively in the AF group, but in both groups after surgery there is likely undetected AF that may be associated with late TR.

Study Limitations We acknowledge several limitations of this study. Given the retrospective nature of our investigation, we were unable to create groups of comparable sizes, and the impact of unknown confounders is always a concern. TR measurements by preoperative transthoracic echocardiography can be altered by changes in preload and afterload conditions. Also, 3-dimensional analysis was not applied, so the 3-dimensional parametric computation of TV annulus diameter could not be used as a control. In the future, 3-dimensional echocardiography will certainly allow for more precision measurement of the tricuspid annulus. Late echocardiograms were performed by cardiologists for periodic surveillance, symptoms, or a new murmur, not according to a predefined schedule. We sought to identify AF status at the time of late TR evaluation, but found that this type of information was not readily retrievable. Also, patients may have been having paroxysmal AF but may have been in sinus rhythm at the time the follow-up echocardiogram was performed, so establishing a clear temporal association between AF and late TR would not be reliable. CONCLUSIONS In patients undergoing MV surgery for DMR with less than moderate TR, our results suggest that (1) for patients without AF, the addition of TVA for those with a

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Probability of TR ≥ Moderate

80%

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McCarthy et al

Original Groups

60%

Probability of TR ≥ Moderate

50%

A

Preop AFib

40% 30% 20%

No Preop AFib Preop AFib

Adjusted

10%

No Preop AFib Preop AFib

HR (95% CI)

P-value

REF

REF

2.84 (2.07, 3.89)

< .001

ADULT

REF

REF

2.25 (1.52, 3.32)

< .001

HR (95% CI)

P-value

0%

0

2

591 178

517 132

4 Years Since Surgery 395 97

6

8

298 66

216 44

Propensity Score-Matched Groups

50% Probability of TR ≥ Moderate

Group

Unadjusted

No Preop AFib

60%

B

Model

Preop AFib

40% 30%

Model

Group

Unadjusted

No Preop AFib

No Preop AFib 20%

Preop AFib Adjusted

No Preop AFib Preop AFib

REF

REF

2.24 (1.36, 3.66)

.0014

REF

REF

2.69 (1.58, 4.58)

< .001

10% 0%

0

2

273 134

235 101

4 Years Since Surgery 171 73

6

8

122 52

78 33

FIGURE 3. Time-evolving probability of developing late TR greater than moderate by presence of preoperative AF in patients who did not receive TVA in the original groups (A) and PS-matched groups (B). Unadjusted and covariate-adjusted HRs for preoperative AF status, together with 95% confidence intervals, are presented. TR, Tricuspid regurgitation; HR, hazard ratio; CI, confidence interval; AFib, atrial fibrillation.

preoperative tricuspid annulus less than 45 mm may not be necessary; (2) for patients with a tricuspid annulus greater than 45 mm, TVA appears to be warranted with or without a history of AF; and (3) for patients with AF, there is a 8

significant, steadily increasing, and thus unrecognized risk of late TR even with concomitant AF ablation. Therefore, it is reasonable to consider tricuspid annuloplasty in these patients.

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Risk and impact of late tricuspid valve regurgitation in patients after degenerative mitral valve surgery Tricuspid annular dimensions ≥ 45 mm increased the risk of late tricuspid regurgitation, but not 40-44 mm.

60% TAD ≥ 45mm 40%

Model

TAD Group

HR (95% CI)

P-value

Unadjusted

< 40mm 40-44mm ≥ 45mm

REF 0.92 (0.53, 1.59) 2.47 (1.34, 4.57)

REF .76 .004

Adjusted

< 40mm 40-44mm ≥ 45mm

REF 0.63 (0.32, 1.28) 3.25 (1.54, 6.87)

REF .20 .002

HR (95% CI)

P-value

TAD < 40mm 20% TAD 40 – 44mm 0% 0

2

423 89 27

354 70 16

4 Years Since Surgery 246 49 11

6

8

158 26 9

79 14 8

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Probability of TR ≥ Moderate

80%

Preoperative atrial fibrillation, even though treated in 97% of patients, was associated with an increased risk of late tricuspid regurgitation. 60%

Probability of TR ≥ Moderate

50% Preop AFib

40% 30% 20%

Model

Group

Unadjusted

No Preop AFib

No Preop AFib

Preop AFib Adjusted

10%

No Preop AFib Preop AFib

REF

REF

2.84 (2.07, 3.89)

< .001

REF

REF

2.25 (1.52, 3.32)

< .001

0% 0

2

591 178

517 132

4 Years Since Surgery 395 97

6

8

298 66

216 44

Late ≥ moderate tricuspid valve regurgitation was associated with increased late mortality: unadjusted HR 3.58 (2.04, 6.29), P-value < .001; adjusted HR 2.37 (1.23, 4.57), P-value = .010 FIGURE 4. The occurrence of late TR in patients with less than moderate TR undergoing surgery for DMR and the importance of AF and TAD were evaluated in 869 patients undergoing MV repair. TR development probabilities estimated over time were lower among patients with TAD less than 40 mm or 40 to 45 mm compared with the group with TAD greater than 45 mm. Developing late moderate or greater TR was associated with increased late mortality. TR, Tricuspid regurgitation; TAD, tricuspid annular dilation; HR, hazard ratio; CI, confidence interval; AFib, atrial fibrillation.

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Webcast You can watch a Webcast of this AATS meeting presentation by going to: https://aats.blob.core.windows.net/ media/19%20AM/Monday_May6/206F/206F/S81%20-% 20Tricuspid%20valve%20surgery%20essentials/S81_8_ webcast_031924008.mp4.

12.

13. 14.

15.

16.

17.

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Conflict of Interest Statement Dr Cox: Atricure: consultant, stockholder, salary; Adagio Medical: BOD, co-founder, consultant, stockholder, salary; SentreHEART: consultant, stockholder, salary; PAVmed: BOD, stockholder; Lucid Diagnostics: BOD, stockholder. Dr McCarthy: Edwards Lifesciences: Consultant, Royalties, Atricure and Medtronic: speaker fees; Abbott; Advisory Board. Dr Thomas: Personal Fees: Edwards Lifesciences, Abbott, GE, Caption Health. All other authors have nothing to disclose with regard to commercial support.

18.

19.

tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J Thorac Cardiovasc Surg. 2011;141:1431-9. Calafiore AM, Gallina S, Iaco AL, Contini M, Bivona A, Gagliardi M, et al. Mitral valve surgery for functional mitral regurgitation: should moderate-ormore tricuspid regurgitation be treated? a propensity score analysis. Ann Thorac Surg. 2009;87:698-703. Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. 2005;112:I453-7. Gertz ZM, Raina A, Saghy L, Zado ES, Callans DJ, Marchlinski FE, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. J Am Coll Cardiol. 2011;58:1474-81. Silbiger JJ. Does left atrial enlargement contribute to mitral leaflet tethering in patients with functional mitral regurgitation? Proposed role of atriogenic leaflet tethering. Echocardiography. 2014;31:1310-1. Liang JJ, Silvestry FE. Mechanistic insights into mitral regurgitation due to atrial fibrillation: ‘‘Atrial functional mitral regurgitation’’. Trends Cardiovasc Med. 2016;26:681-9. Utsunomiya H, Itabashi Y, Mihara H, Berdejo J, Kobayashi S, Siegel RJ, et al. Functional tricuspid regurgitation caused by chronic atrial fibrillation: a real-time 3-dimensional transesophageal echocardiography study. Circ Cardiovasc Imaging. 2017;10. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14: e275-444. Mehta CK, McCarthy PM, Andrei AC, Kruse J, Shi H, Churyla A, et al. De novo atrial fibrillation after mitral valve surgery. J Thorac Cardiovasc Surg. 2018;156: 1515-25.e11.

Key Words: degenerative mitral regurgitation, mitral valve repair, atrial fibrillation, tricuspid annular dilation, tricuspid regurgitation

References 1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:2440-92. 2. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/ EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739-91. 3. Stulak JM, Schaff HV, Dearani JA, Orszulak TA, Daly RC, Sundt TM III. Restoration of sinus rhythm by the Maze procedure halts progression of tricuspid regurgitation after mitral surgery. Ann Thorac Surg. 2008;86:40-5. 4. Wang J, Han J, Li Y, Ye Q, Meng F, Luo T, et al. Impact of surgical ablation of atrial fibrillation on the progression of tricuspid regurgitation and right-sided heart remodeling after mitral-valve surgery: a propensity-score matching analysis. J Am Heart Assoc. 2016;5:e004213. 5. Kim HK, Kim YJ, Kim KI, Jo SH, Kim KB, Ahn H, et al. Impact of the maze operation combined with left-sided valve surgery on the change in tricuspid regurgitation over time. Circulation. 2005;112:I14-9. 6. Ito K, Abe Y, Takahashi Y, Shimada Y, Fukumoto H, Matsumura Y, et al. Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: a study using three-dimensional transesophageal echocardiography. J Cardiol. 2017;70:584-90. 7. Kim DH, Heo R, Handschumacher MD, Lee S, Choi YS, Kim KR, et al. Mitral valve adaptation to isolated annular dilation: insights into the mechanism of atrial functional mitral regurgitation. JACC Cardiovasc Imaging. 2019;12:665-77. 8. Badhwar V, Rankin JS, Damiano RJ Jr, Gillinov AM, Bakaeen FG, Edgerton JR, et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg. 2017;103:329-41. 9. McCarthy PM. Adjunctive procedures in degenerative mitral valve repair: tricuspid valve and atrial fibrillation surgery. Semin Thorac Cardiovasc Surg. 2007;19:121-6. 10. 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;79:127-32. 11. 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

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Discussion Dr Niv Ad (Falls Church, Va). I think this article is one of the most important that was presented concerning structural heart disease conceptually, because it shows that there is more to tricuspid valve insufficiency secondary to DMR than just the size of the annulus. I think it will open vast information related to the physiology associated with tricuspid valve insufficiency that may reflect on our decision-making. That being said, maybe we should look into diastolic dysfunction, RV and right atrial strains, and understand better pulmonary hypertension, because the size is just a reflection of the pathophysiology, and the fact that you found that AF is so important is just showing us that there is some physiology joining the size itself. I congratulate you on the study on the research question and the way it was conducted. I have 3 questions that I hope can be answered rather quickly and let others discuss them if they want. The first is related to your technical timing of the assessment of the disease. Do you assess the size of the tricuspid valve before surgery? The reason I am asking is that we know that for

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functional MR, for instance, intraoperative analysis is useless. So how much and how far in advance do you do it and how do you measure the valve to get to the size of 40 to 45 mm or more? Dr Michal Szlapka (Chicago, ll). Dr McCarthy wanted to comment on that.

Dr Patrick M. McCarthy (Chicago, Ill). This is an important point. The numbers were all on the preoperative transthoracic echo. They were not the intraoperative numbers. When we talk to patients, we have already made the decision before surgery; everyone with moderate or greater is going to receive tricuspid repair. We will tell some patients if the annulus is large on intraoperative echo or the TR is worse, then I may decide to add it. But I don’t decide not to do a TV repair because the TR is only mild intraoperatively. So we ignore intraoperative downgrade, like we do with ischemic MR. Dr Ad. Why do you think that preoperative atrial fibrillation is an important predictor? Is it because some physiologic and pathophysiological changes are directly related to atrial fibrillation or is atrial fibrillation a marker to a more complex patient who has pulmonary hypertension, diastolic dysfunction, and all those other things? Dr Szlapka. There has been growing evidence in the literature that AF may cause both mitral and tricuspid valve

regurgitation, this entity referred to as functional mitral or functional TR. AF itself may cause annular dilation. That is why it has an impact on occurrence of this pathology in these patients. I read an article from Dr Utsunomiya published in Circulation. The incidence of tricuspid functional regurgitation was not uncommon; according to this article, it reached up to 9%. So probably it’s a new type of disease we should be looking at. Dr McCarthy. I will amplify that a bit, Dr Ad. We operated for years, you and I, on patients with MR with long-standing AF. More recently we are recognizing atrial functional MR and TR. These patients have big left and right atria with no prolapse and type I dysfunction. In this study, we were not able to study variables like right atrial size or right atrial volume. After the surgery, we had more than 80% freedom from atrial fibrillation, so the cause of progressive TR wasn’t from most patients returning to AF. Some did, but other factors likely contributed. I completely agree with your comments about these other factors. RV and right atrial strain may help us in the future as we get more sophisticated studies like that. Dr Ad. Finally, what do you do now with your decisionmaking? Do you stay with the 40 or go more to the Tirone David approach, the previous debate from a couple of years ago? How did you change your decision-making? Dr McCarthy. For the group of patients with tricuspid annular diameter of 45 mm or more, we add tricuspid annuloplasty. For patients with 40 to 44 mm, I would treat the patients who had a history of right heart failure or other clinical indications, but otherwise no, so we are more in the Tirone David camp. In the entire group of patients with less than moderate TR, only 3.6% had tricuspid valve repair.

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Age Body Surface Area Body Mass Index CHADS2 Ejection Fraction Creatinine Level Gender (female) Diabetes Dyslipidemia Hypertension Chronic Lung Disease Cerebrovascular Disease Previous MI Congestive Heart Failure

ADULT

NYHA Class III IV Repeat Sternotomy None/trivial TR Mild TR CABG Aortic Valve Surgery MV repair MV replacement No TAD TAD < 40 TAD 40-44 TAD >= 45 -0.4

-0.2 0.0 0.2 0.4 Standardized Mean Difference Original Groups

PS-Matched Groups

FIGURE E1. Display of standardized mean differences for variables used in the PS model created to compare outcome by preoperative AF status. Standardized mean differences after PS matching are reduced compared with those observed in the original samples, indicating that adequate baseline covariate balance has been achieved. PS, Propensity score; MI, myocardial infarction; NYHA, New York Heart Association; TR, tricuspid regurgitation; CABG, coronary artery bypass grafting; MV, mitral valve; TAD, tricuspid annular dilation.

11.e1

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N Overall and per group

Entire cohort (N ¼ 869)

No follow-up echocardiography (N ¼ 100)

Follow-up echocardiography (N ¼ 769)

P value

869 (100,769)

59.3  12.1

61.2  13.7

59.0  11.9

.098

869 (100,769)

2.0  0.2

2.0  0.3

2.0  0.2

.078

Body mass index (kg/m )

869 (100,769)

26.5  4.5

26.9  3.5

26.5  4.6

.372

CHADS2

869 (100,769)

0.9  0.9

0.9  1.0

0.8  0.9

.336

Variable Age (y) 2

Body surface area (m ) 2

CHADS2VASC

869 (100,769)

1.5  1.3

1.6  1.4

1.5  1.3

.426

Tricuspid annulus size (mm)

657 (88,569)

35.4  6.1

34.9  4.9

35.5  6.2

.370

LA volume

680 (88,592)

102.0  46.0

100.8  35.2

102.2  47.5

.795

LA volume index

678 (88,590)

51.9  22.3

50.1  15.9

52.1  23.1

.425

LA size

749 (91,658)

4.4  0.7

4.3  0.6

4.4  0.8

.551

Creatinine level, median (Q1, Q3)

866 (100,766)

1.0 (0.8, 1.1)

1.0 (0.9, 1.2)

1.0 (0.8, 1.1)

.004

Ejection fraction, median (Q1, Q3)

863 (99,764)

60.0 (57.0, 65.0)

61.0 (60.0, 65.0)

60.0 (57.0, 65.0)

.027

Tricuspid annulus 40

657 (88,569)

163 (25%)

17 (19%)

146 (26%)

.200

Tricuspid annulus 45

657 (88,569)

51 (8%)

2 (2%)

49 (9%)

.039

Gender (female)

869 (100,769)

265 (30%)

25 (25%)

240 (31%)

.205

Infectious endocarditis

869 (100,769)

32 (4%)

2 (2%)

30 (4%)

.342

Diabetes

868 (100,768)

37 (4%)

8 (8%)

29 (4%)

.049

Dialysis

869 (100,769)

2 (0%)

0 (0%)

2 (0%)

.610

Pulmonary hypertension

682 (77,605)

301 (44%)

34 (44%)

267 (44%)

.997

Dyslipidemia

869 (100,769)

395 (45%)

50 (50%)

345 (45%)

.332

Hypertension

869 (100,769)

431 (50%)

50 (50%)

381 (50%)

.932

Chronic lung disease

867 (100,767)

44 (5%)

2 (2%)

42 (5%)

.136

Peripheral vascular disease

869 (100,769)

9 (1%)

0 (0%)

9 (1%)

.277

Cerebrovascular disease

868 (99,769)

34 (4%)

5 (5%)

29 (4%)

.537

Prior stroke

868 (99,769)

18 (2%)

3 (3%)

15 (2%)

.478

Previous MI

864 (99,765)

24 (3%)

3 (3%)

21 (3%)

.871

Congestive heart failure

869 (100,769)

126 (14%)

16 (16%)

110 (14%)

.651

Prior CABG

869 (100,769)

12 (1%)

2 (2%)

10 (1%)

.573

Repeat sternotomy

869 (100,769)

22 (3%)

3 (3%)

19 (2%)

.751

NYHA Class III IV

868 (100,768)

111 (13%)

15 (15%)

96 (13%)

.481

Tricuspid Insufficiency 0 ¼ None/Trivial 1 ¼ Mild

869 (100,769) 526 (61%) 343 (39%)

62 (62%) 38 (38%)

464 (60%) 305 (40%)

.749

CABG

869 (100,769)

124 (14%)

15 (15%)

109 (14%)

.824

Aortic valve surgery

869 (100,769)

36 (4%)

6 (6%)

30 (4%)

.322

Tricuspid valve surgery

869 (100,769)

31 (4%)

1 (1%)

30 (4%)

.141

AF duration (y)

190 (20,170)

AF ablation surgery

869 (100,769)

2.7  4.5 194 (22%)

1.9  2.0 21 (21%)

2.8  4.7 173 (22%)

.381 .735 (Continued)

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TABLE E1. Perioperative characteristics by availability of echocardiography information in follow-up

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TABLE E1. Continued

Variable

N Overall and per group

AF type Paroxysmal Permanent Persistent

194 (21,173)

AF ablation type Biatrial Classic Left only

193 (21,172)

MV surgery Repair Replacement

869 (100,769)

Entire cohort (N ¼ 869)

No follow-up echocardiography (N ¼ 100)

Follow-up echocardiography (N ¼ 769)

P value .724

134 (69%) 35 (18%) 25 (13%)

13 (62%) 5 (24%) 3 (14%)

121 (70%) 30 (17%) 22 (13%)

35 (18%) 11 (6%) 147 (76%)

3 (14%) 2 (10%) 16 (76%)

32 (19%) 9 (5%) 131 (76%)

846 (97%) 23 (3%)

94 (94%) 6 (6%)

752 (98%) 17 (2%)

.671

.026

CHADS2, Congestive heart failure, hypertension, age, diabetes, stroke; CHADS2VASC, congestive heart failure, hypertension, age, diabetes, stroke, vascular disease; LA, left atrial; MI, myocardial infarction; CABG, coronary artery bypass grafting; NYHA, New York Heart Association; AF, atrial fibrillation; MV, mitral valve.

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The relationship of atrial fibrillation and tricuspid annular dilation to late tricuspid regurgitation in patients with degenerative mitral repair Patrick M. McCarthy, MD, Michal Szlapka, MD, Jane Kruse, BSN, Olga N. Kislitsina, MD, James D. Thomas, MD, Menghan Liu, MS, Adin-Cristian Andrei, PhD, and James L. Cox, MD, Chicago, Ill In patients with DMR undergoing mitral surgery with less than moderate TR preoperatively, TV annular diameter 45 mm or more and AF (despite ablation in 97%) were associated with late moderate or more TR.

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000

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