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Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation
IJCA-23799; No of Pages 5 International Journal of Cardiology xxx (2016) xxx–xxx
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation Takeshi Kitai a,e,⁎, Yutaka Furukawa a, Kenta Murotani c, Chayakrit Krittanawong e, Shuichiro Kaji a, Tadaaki Koyama b, Yukikatsu Okada d a
Departments of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minami machi, Chuo-ku, Kobe 650-0047, Japan Departments of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minami machi, Chuo-ku, Kobe 650-0047, Japan Division of Biostatistics, Clinical Research Center Aichi Medical University, 1-1 Yazakokarimata, Nagakute 480-1195, Japan d Heart Valve Center, Department of Cardiovascular Surgery, Modori Hospital, 1-16 Edayoshi, Nishi-ku, Kobe 651-2133, Japan e Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA b c
a r t i c l e
i n f o
Article history: Received 20 July 2016 Received in revised form 20 October 2016 Accepted 22 October 2016 Available online xxxx Keywords: Mitral valve surgery Tricuspid valve Tricuspid regurgitation
a b s t r a c t Background: The aim of this study was to determine optimal patient selection and selection of a prosthetic ring size for tricuspid valve (TV) repair at the time of mitral valve (MV) repair. Methods: We prospectively enrolled 167 consecutive patients undergoing MV repair. TV repair was indicated if patients had at least one of the following conditions representing tricuspid annular dilatation: (1) tricuspid regurgitation (TR) ≥ moderate, (2) history of right heart failure, (3) atrial fibrillation, and (4) pulmonary hypertension. The size of the ring was targeted to a normal-sized systolic tricuspid annuls in relation to the patient's body surface area (BSA). Serial echocardiographic studies were performed preoperatively, at discharge, and at 1, 3, and 5 years postoperatively. Results: Overall, 100 (60%) patients required TV repair, while it was not indicated for 67 (40%) patients. During follow-up, 26 patients showed progression or recurrent TR ≥ moderate. The TR grade at 5 years after MV surgery was 0.8 ± 0.9 in patients with TV repair and 0.9 ± 0.7 in those without TV repair (P = 0.69). There were no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate (P = 0.46). Conclusions: Patient selection for TV repair considering not only the grade of TR but clinical signs representing tricuspid annular dilatation is feasible at the time of MV repair. TV repair targeting a normal systolic size in relation to the BSA is a simple and reproducible procedure. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction As degenerative valve disorders increase in frequency as the population ages, degenerative mitral regurgitation (MR) has become the most common cause of mitral valve (MV) surgery. MV repair is feasible in most patients with degenerative MR, and the freedom from reoperation is very high. However, a consistent number of patients develop significant functional tricuspid regurgitation (TR) following MV repair, and significant TR has been reported as being responsible for an increase in mortality late after MV surgery [1–6]. Accordingly, as recognition of the negative effect of functional TR after MV surgery has increased, surgical indications for tricuspid valve (TV) repair at the time of MV surgery have been extended to include not only the severity of TR but also dilatation of the tricuspid annulus [7–9]. However, the prognostic value of
this recommendation has not been prospectively evaluated. The standard surgical technique of TV repair for functional TR is tricuspid annuloplasty, which has a favorable effect on mortality in comparison with suture technique, such as De Vega's or Kay's technique [7,10–15]. There remains a debate, however, regarding size selection for the prosthetic ring in TV repair. Moreover, because of the changes in the tricuspid annular shape and size during the cardiac cycle, an established method for determining the optimal tricuspid annular size and motion is still lacking. Therefore, we conducted a prospective clinical study concerning patient selection and selection of a prosthetic ring size for TV repair, and clinical outcomes with and without TV repair for patients undergoing MV repair for severe MR. 2. Methods 2.1. Study population
⁎ Corresponding author at: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44122, USA. E-mail address: [email protected] (T. Kitai).
A total of 167 consecutive patients with severe MR who were scheduled for MV repair were prospectively included in this study from September 2007 to March 2010. Among
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Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
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T. Kitai et al. / International Journal of Cardiology xxx (2016) xxx–xxx
these patients, TV repair was indicated at the time of MV repair if they had at least one of the following conditions: (1) TR ≥ moderate, (2) history of right heart failure, defined as a significant lower extremity edema, pleural effusion or ascites requiring diuretics, (3) atrial fibrillation, and (4) pulmonary hypertension, defined as estimated right ventricular systolic pressure (RVSP) N 50 mm Hg. Patients who would require additional tricuspid procedures beyond ring annuloplasty were excluded from this study. According to these criteria, 100 patients (60%) required TV repair while 67 patients (40%) who did not have any of the aforementioned conditions were not indicated for TV repair. Among the 100 patients who required TV repair based on the criteria, 7 did not undergo TV repair. Therefore, we compared 93 patients with TV repair and 67 patients without TV repair in the perprotocol analysis. The CONSORT diagram shows our strategy for the patient selection (Fig. 1). This study was prospectively designed and approved by our Institutional Review Board, and all participants provided written informed consent.
2.2. Surgical procedures The procedures were performed with the use of mild hypothermic cardiopulmonary bypass with intermittent antegrade and/or retrograde cold blood cardioplegia for myocardial protection. Double venous cannulation was used. After establishment of cardiopulmonary bypass, cardiac arrest was obtained by infusion of cold blood cardioplegia. MV repair was performed using simplified and reproducible techniques as previously reported [16,17]. In brief, resection and suture were performed for prolapsed posterior leaflet, and the height of the remaining posterior leaflet was reduced to less than 15 mm using a sliding technique or folding procedure, if necessary. Chordal reconstruction with expanded polytetrafluoroethylene was performed to repair the anterior leaflet. Mitral ring annuloplasty was routinely performed using a flexible complete ring or a band. Intraoperative transesophageal echocardiography was routinely performed to evaluate residual regurgitation. During the Maze procedure, both right and left atrial appendages were excluded. The summary of the procedure for TV repair is illustrated in the Central Picture. The first stitch (2-0 braided suture) was made at the annulus of the anterior leaflet at the anterior– septal commissure, after which a horizontal mattress suture at the annulus of the septal leaflet was placed. The distance between the anterior and septal stitches was the same as the band size, and the circumferential length was three times the band size (Fig. 2). Plication was carefully measured from the antero-posterior commissure to the posteroseptal commissure. Half of the band corresponded to the anterior annulus and the other half to the posterior annulus and part of the septal annulus. A small RB1 needle was applied to prevent kinking of the band after implantation. Annular stitches along the anterior tricuspid leaflet corresponded to half of the band. Ten to twelve bites were required according to dilatation of the annulus. Constant circumferential length can be obtained in the same size of band. A flexible band (Tailor™, St. Jude Medical, St. Paul, MN, USA) was used in all the procedures for TV repair in this study. As the systolic tricuspid annulus area is reported as 3.9 cm2/m2 in normal subjects [18], patient's tricuspid circumferential length was estimated along with
each patient's body surface area (BSA). Therefore, we selected the size of the ring from four possible options (25, 27, 29, and 31 mm). 2.3. Echocardiographic evaluation and clinical outcomes Echocardiographic data were analyzed before surgery, at discharge following the surgery, and at 1, 3, and 5 years after surgery. Two-dimensional echocardiography and Doppler color-flow imaging were performed in all patients. TR severity was assessed in accordance with the criteria of the American Society of Echocardiography [19]. Color Doppler images were obtained in at least two orthogonal planes. Right ventricular systolic pressure was estimated using continuous-wave Doppler and the simplified Bernoulli equation of TR peak velocity [19]. The tricuspid annulus was reconstructed and measured by transthoracic real-time three-dimensional (3D) echocardiography before and after the surgery as previously reported [20]. The primary outcome measure was a composite of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate. The grade of TR was recorded at discharge following the surgery, and at 1, 3, and 5 years postoperatively. 2.4. Statistical analysis Categorical variables are shown as numbers and percentages and were compared using the chi-square test or Fisher's exact test, as appropriate. Continuous variables are expressed as mean and standard deviation or median and interquartile range. Based on their distribution, continuous variables were compared using Student's t-test or the Wilcoxon rank sum test. Two-sided P-values b 0.05 were considered statistically significant. A nonparametric repeated-measures analysis of variance (Friedman test) was used to test statistical differences in the TR grade with time among the groups, and the Wilcoxon signed-rank test was used to test statistical differences between each time group. The Kaplan–Meier method was used to estimate cumulative event-free survival, and differences in survival curves were compared using the log-rank test. All analyses were performed with the statistical software program JMP Pro 10.0.0 (SAS institute, Cary, NC, USA).
3. Results 3.1. Baseline patient characteristics and preoperative echocardiography The clinical features of the 167 patients enrolled are summarized in Table 1. There were 104 (62%) men and 63 (38%) women with a mean age of 59 ± 15 years. Transthoracic echocardiography was performed
Fig. 1. CONSORT diagram of the study patients.
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
T. Kitai et al. / International Journal of Cardiology xxx (2016) xxx–xxx
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Fig. 2. Representative illustration for tricuspid valve repair.
before surgery in all patients. The mean LV ejection fraction, LV enddiastolic dimension, and LV end-systolic dimension were 63 ± 9%, 55 ± 7 mm and 34 ± 8 mm, respectively. Atrial fibrillation was detected in 48 (29%) patients preoperatively and pulmonary hypertension was seen in 33 (20%) patients. Twenty-eight patients had severe heart failure symptoms before surgery. Baseline characteristics stratified according to whether or not patients underwent TV repair, for the intension-to-treat analysis are shown in Table 1. Patients with TV repair were associated with older age and a higher prevalence of severe heart failure symptoms and concomitant Maze procedure, as well as larger left atrial size and higher pulmonary artery systolic pressure. The tricuspid annulus diameter of patients without TV repair was significantly smaller than that of those with TV repair in both the diastolic (28.7 ± 5.1 vs 24.6 ± 3.5 mm, P b 0.001) and systolic phases (23.8 ± 4.7 vs 19.2 ± 3.0 mm, P b 0.001). 3.2. Surgical procedures MV reparative procedures included resection and suture for prolapsed posterior leaflet (n = 109), chordal reconstruction with GoreTex (CV-5) for anterior prolapse (n = 59), glutaraldehyde-treated autologous pericardial patch (n = 27), and ring annuloplasty (n = 163). Concomitant procedures included aortic valve replacement (n = 20), maze procedure (n = 52), and coronary artery bypass grafting (n = 14). MV procedures and concomitant procedures are summarized in Table 2. Mean BSA of the patients was 1.73 ± 0.16 m2; a 27-mm prosthesis was selected for 46 (49%) patients and a 29-mm prosthesis for 45
Table 1 Patient characteristics and preoperative echocardiographic indices.
Age, year, mean ± SD Male, n (%) NYHA functional class III or IV, n (%) Preoperative echocardiography LV ejection fraction, % LV end-diastolic dimension, mm LV end-systolic dimension, mm Left atrial dimension, mm Estimated PA systolic pressure, mmHg Tricuspid annular diameter in diastole Tricuspid annular diameter in systole Indications for tricuspid annuloplasty, n (%) Tricuspid regurgitation (≥moderate) Atrial fibrillation Pulmonary hypertension History of right heart failure
(48%) patients. The diastolic diameter of the tricuspid annulus was significantly decreased after TV repair (28.7 ± 5.1 vs 19.9 ± 3.6 mm, P b 0.001), similar to the systolic diameter of the tricuspid annulus in patients without TV repair (19.9 ± 3.6 vs 19.2 ± 3.0 mm, P = 0.72).
3.3. Outcomes and recurrent or development of tricuspid regurgitation after mitral valve surgery The median follow-up period was 6.5 (interquartile range: 5.2 to 7.2) years after MV surgery. During follow-up there were 4 deaths and 3 re-do surgeries, and 8 patients developed recurrence of severe MR. A total of 26 patients showed progression or recurrent TR ≥ moderate, including 4 patients with severe TR. The TR grade at discharge and at 1, 3, and 5 years, respectively, was 0.3 ± 0.5, 0.5 ± 0.6, 1.0 ± 0.7, and 0.8 ± 0.9 in patients with TV repair and 0.4 ± 0.5, 0.4 ± 0.5, 1.1 ± 0.5, and 0.9 ± 0.7 in those without TV repair (Fig. 3). Freedom from recurrence or progression to TR ≥ moderate at 1, 3 and 5 years after MV surgery was 91, 83, and 83% in patients with TV repair and 92, 85, and 84% in those without TV repair, respectively (P = 0.82). The Kaplan–Meier survival curve showed no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate (P = 0.46, Fig. 4). In 33 patients who had preoperative pulmonary hypertension (RVSP: 58.7 ± 9.9 mm Hg), RVSP was
Table 2 Surgical procedures, and tricuspid prosthesis selection.
TV repair (+) (n = 100)
TV repair (−) (n = 67)
P
64 ± 14 57 (57) 22 (22)
53 ± 13 47 (70) 6 (9)
b0.001 0.10 0.03
62 ± 9 54 ± 8 34 ± 8 49 ± 7 45 ± 13 28.7 ± 5.1 23.8 ± 4.7
65 ± 9 55 ± 7 33 ± 7 42 ± 7 34 ± 6 24.6 ± 3.5 19.2 ± 3.0
0.06 0.48 0.50 b0.001 b0.001 b0.001 b0.001
59 (59) 48 (48) 33 (33) 59 (59)
0 (0) 0 (0) 0 (0) 0 (0)
b0.001 b0.001 b0.001 b0.001
TV = tricuspid valve; NYHA = New York Heart Association; LV = left ventricular; PA = pulmonary artery.
Mitral valve procedures Resection and suture of PML Chordal reconstruction with ePTFE Pericardial patch Mitral ring annuloplasty Concomitant surgical procedures Coronary artery bypass graft Aortic valve replacement/repair Maze Size of tricuspid prosthesis 25 mm 27 mm 29 mm 31 mm Postoperative echocardiography Tricuspid annular diameter in diastole Tricuspid annular diameter in systole
TV repair (+) (n = 93)
TV repair(−) (n = 67)
P
65 (70) 36 (39) 14 (15) 90 (97)
44 (66) 23 (34) 13 (19) 66 (99)
0.61 0.57 0.52 0.64
10 (11) 11 (12) 47 (51)
4 (6) 9 (13) 5 (7)
0.40 0.47 b0.001
1 (1) 46 (49) 45 (48) 1 (1)
– – – –
– – – –
19.9 ± 3.6 15.1 ± 2.9
23.1 ± 3.8 17.8 ± 3.0
b0.001 b0.001
TV = tricuspid valve; PML = posterior mitral leaflet; ePTFR = expanded polytetrafluoroethylene.
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
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Fig. 3. Recurrence or progression of tricuspid regurgitation over time after mitral valve surgery.
significantly decreased at discharge (33.5 ± 7.1 mm Hg) and remained practically unchanged 1-year (36.4 ± 11.9 mm Hg) and 3-year after surgery (26.1 ± 12.9 mm Hg). 4. Discussion In this study, we assessed the long-term outcomes of patients who underwent MV repair with and without TV repair. The selection of patients for TV repair was based on the criteria listed in the Study Population section, and selection of the appropriate size of annuloplasty ring was based on patient's BSA. TR recurrence was acceptable according to our strategy, as was new development of TR in patients without TV repair. Functional TR was historically considered to be a benign disease that would disappear once MR had been treated. However, increasing evidence has shown that TR does not regress spontaneously, and may even develop and worsen over time in patients not undergoing TV repair at the time of MV surgery [1,6,21]. Therefore, TV repair accompanying MV surgery has recently become increasingly common, even if TR is not severe but when tricuspid annulus is dilated [7,8,19,22]. Given that surgical correction of MR alone does not correct tricuspid annular dilatation, such dilatation, if present, is progressive and, although it may not be accompanied by TR initially, eventually leads to the development
Fig. 4. The Kaplan–Meier estimates of freedom from all-cause death, re-do mitral and/or tricuspid surgery, and recurrence or progression of tricuspid regurgitation of moderate extent or worse.
and worsening of TR [7]. In addition, as functional TR after MV repair is associated with poor survival and functional status [13,23–26], TV repair regardless of the absolute grade of TR at the time of MV surgery could theoretically halt the progression of TR and be associated with a better prognosis. However, there is still insufficient scientific evidence for prophylaxis in cases of minimal or absent TR, even in cases with tricuspid annular dilatation. The normal tricuspid annulus has a nonplanar or saddle-like structure with distinct high points located anteriorly and posteriorly, and low points located septally and laterally [18,27]. In patients with functional TR, the annulus becomes dilated, flatter, and more circular, with a decreased mediolateral-to-anteroposterior ratio [28]. Thus, reported abnormality of the tricuspid annulus has included not only dilatation, but also deformity of the saddle-shaped annulus [18,20,28]. Moreover, because the shape and size of the tricuspid annulus are dynamic during the cardiac cycle, the reproducible and reliable measurement of the tricuspid annulus and the diagnosis of tricuspid annular dilatation remain difficult. Although 3D echocardiography provides additional data on TV annulus beyond 2D echocardiography, accurate assessment of TV annulus can still be difficult because of its asymmetric saddle shape and movement during the cardiac cycle [18,20,28,29]. Therefore, clinical conditions that represent tricuspid annular dilation should be taken into account during the decision-making of process for TV repair. In the current study, we included history of right heart failure, pulmonary hypertension, and atrial fibrillation as conditions suggesting tricuspid annular dilatation. Pulmonary hypertension has been shown to correlate approximately with severity of functional TR [29]. Atrial fibrillation has been shown to be associated with TR progression after MV surgery, in addition to annular dilatation and pulmonary hypertension [8]. Pulmonary hypertension and atrial fibrillation are well known as risk factors for the development of functional TR [2]. We included these conditions that require TV repair regardless of TR grade. Moreover, a clinical history of right heart failure is strongly suspected to lead to a more than moderate TR associated with annulus dilatation. As little is known regarding the normal and pathological size of the tricuspid annulus, we selected the size of the ring designed for a normal-sized tricuspid annulus in systole according to the patient's BSA [18]. Another challenge is to test the rationale for the strategy that TV repair is not indicated unless the tricuspid annulus is dilated. Little is known regarding whether patients without tricuspid annular dilatation still go on to develop TR during follow-up after MV surgery. Because the absence of annular dilatation at the time of MV surgery does not guarantee against future annular dilatation or future development of functional TR, a question arises concerning whether TV repair should routinely be performed in all cases of MV surgery regardless of tricuspid annular dilatation or TR grade. In the current study, TV repair was not indicated in 67 patients (40%) who did not have any conditions including (1) TR ≥ moderate, 2) history of right heart failure, (3) pulmonary hypertension, and (4) atrial fibrillation. Patients who did not undergo TV repair had 84.8% free rate from significant TR 5 years after surgery. Our data support the concept that prophylactic TV repair is not required when the tricuspid annulus is not dilated. In addition, although it is reported that concomitant TV repair did not significantly increase the preoperative mortality and morbidity [30], TV repair is not an entirely benign intervention. Therefore, we do not think there is sufficient justification to extend the liberal use of TV repair to all the patients undergoing MV surgery. However, clinician should remain aware of some patients who develop late TR despite not showing any of the indications for TV repair at the time of MV surgery. The main limitation of the present study is that it was not a randomized comparison of TV repair in patients with tricuspid annular dilatation. A randomized study is needed to investigate whether TV repair can improve outcome in patients who had TV annular dilation. However, it may raise some ethical difficulties because of the current guidelines recommendation for TV repair. Second, TR grade was not quantified in this study, and semi-quantitative measurement of TR severity based on TR
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
T. Kitai et al. / International Journal of Cardiology xxx (2016) xxx–xxx
jet area was used. Nevertheless, semi-quantitative measurement of TR is widely used in clinical practice. Third, because echocardiographic followup was incomplete, the potential for under- or overestimation of the incidence of recurrent symptomatic severe TR should be acknowledged. We did not investigate right ventricular function and detailed geometric changes in right ventricular shape. Finally, the study was performed in a single center, which led to limitations in the generalization of results. 5. Conclusions Patient selection for TV repair based on clinical signs representing tricuspid annular dilatation, rather than exact measures of tricuspid annulus, was feasible at the time of MV repair. Reduction annuloplasty for functional TR targeting a normal systolic size of tricuspid annulus in accordance with BSA was a simple and reproducible procedure. Acknowledgement of grant support None. Conflict of interest statement None. References [1] A. Porter, Y. Shapira, M. Wurzel, J. Sulkes, M. Vaturi, Y. Adler, G. Sahar, A. Sagie, Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation, J. Heart Valve Dis. 8 (1999) 57–62. [2] H. Song, M.J. Kim, C.H. Chung, S.J. Choo, M.G. Song, J.M. Song, D.H. Kang, J.W. Lee, J.K. Song, Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery, Heart 95 (2009) 931–936. [3] J.J. Kwak, Y.J. Kim, M.K. Kim, H.K. Kim, J.S. Park, K.H. Kim, K.B. Kim, H. Ahn, D.W. Sohn, B.H. Oh, Y.B. Park, Development of tricuspid regurgitation late after leftsided valve surgery: a single-center experience with long-term echocardiographic examinations, Am. Heart J. 155 (2008) 732–737. [4] C. Izumi, M. Miyake, S. Takahashi, H. Matsutani, S. Hashiwada, K. Kuwano, H. Hayashi, S. Nakajima, M. Nishiga, K. Hanazawa, J. Sakamoto, H. Kondo, T. Tamura, K. Kaitani, K. Yamanaka, Y. Nakagawa, Progression of isolated tricuspid regurgitation late after left-sided valve surgery. Clinical features and mechanisms, Circ. J. 75 (2011) 2902–2907. [5] A.B. Goldstone, J.L. Howard, J.E. Cohen, J.W. MacArthur Jr., P. Atluri, J.N. Kirkpatrick, Y.J. Woo, Natural history of coexistent tricuspid regurgitation in patients with degenerative mitral valve disease: implications for future guidelines, J. Thorac. Cardiovasc. Surg. 148 (2014) 2802–2809. [6] A. Matsunaga, C.M. Duran, Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation, Circulation 112 (2005) I453–I457. [7] G.D. Dreyfus, P.J. Corbi, K.M. Chan, T. Bahrami, Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann. Thorac. Surg. 79 (2005) 127–132. [8] R.A. Nishimura, C.M. Otto, R.O. Bonow, B.A. Carabello, J.P. Erwin 3rd, R.A. Guyton, P.T. O'Gara, C.E. Ruiz, N.J. Skubas, P. Sorajja, T.M. Sundt 3rd, J.D. Thomas, 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, J. Am. Coll. Cardiol. 63 (2014) 2438–2488. [9] V.P. Harjola, A. Mebazaa, J. Celutkiene, D. Bettex, H. Bueno, O. Chioncel, M.G. CrespoLeiro, V. Falk, G. Filippatos, S. Gibbs, A. Leite-Moreira, J. Lassus, J. Masip, C. Mueller, W. Mullens, R. Naeije, A.V. Nordegraaf, J. Parissis, J.P. Riley, A. Ristic, G. Rosano, A. Rudiger, F. Ruschitzka, P. Seferovic, B. Sztrymf, A. Vieillard-Baron, M.B. Yilmaz, S. Konstantinides, Contemporary management of acute right ventricular failure: a statement from the heart failure association and the working group on pulmonary circulation and right ventricular function of the european society of cardiology, Eur. J. Heart Fail. 18 (2016) 226–241. [10] P.B. Bertrand, G. Koppers, F.H. Verbrugge, W. Mullens, P. Vandervoort, R. Dion, D. Verhaert, Tricuspid annuloplasty concomitant with mitral valve surgery: effects on right ventricular remodeling, J. Thorac. Cardiovasc. Surg. 147 (2014) 1256–1264.
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Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation Takeshi Kitai a,e,⁎, Yutaka Furukawa a, Kenta Murotani c, Chayakrit Krittanawong e, Shuichiro Kaji a, Tadaaki Koyama b, Yukikatsu Okada d a
Departments of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minami machi, Chuo-ku, Kobe 650-0047, Japan Departments of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minami machi, Chuo-ku, Kobe 650-0047, Japan Division of Biostatistics, Clinical Research Center Aichi Medical University, 1-1 Yazakokarimata, Nagakute 480-1195, Japan d Heart Valve Center, Department of Cardiovascular Surgery, Modori Hospital, 1-16 Edayoshi, Nishi-ku, Kobe 651-2133, Japan e Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA b c
a r t i c l e
i n f o
Article history: Received 20 July 2016 Received in revised form 20 October 2016 Accepted 22 October 2016 Available online xxxx Keywords: Mitral valve surgery Tricuspid valve Tricuspid regurgitation
a b s t r a c t Background: The aim of this study was to determine optimal patient selection and selection of a prosthetic ring size for tricuspid valve (TV) repair at the time of mitral valve (MV) repair. Methods: We prospectively enrolled 167 consecutive patients undergoing MV repair. TV repair was indicated if patients had at least one of the following conditions representing tricuspid annular dilatation: (1) tricuspid regurgitation (TR) ≥ moderate, (2) history of right heart failure, (3) atrial fibrillation, and (4) pulmonary hypertension. The size of the ring was targeted to a normal-sized systolic tricuspid annuls in relation to the patient's body surface area (BSA). Serial echocardiographic studies were performed preoperatively, at discharge, and at 1, 3, and 5 years postoperatively. Results: Overall, 100 (60%) patients required TV repair, while it was not indicated for 67 (40%) patients. During follow-up, 26 patients showed progression or recurrent TR ≥ moderate. The TR grade at 5 years after MV surgery was 0.8 ± 0.9 in patients with TV repair and 0.9 ± 0.7 in those without TV repair (P = 0.69). There were no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate (P = 0.46). Conclusions: Patient selection for TV repair considering not only the grade of TR but clinical signs representing tricuspid annular dilatation is feasible at the time of MV repair. TV repair targeting a normal systolic size in relation to the BSA is a simple and reproducible procedure. © 2016 Elsevier Ireland Ltd. All rights reserved.
1. Introduction As degenerative valve disorders increase in frequency as the population ages, degenerative mitral regurgitation (MR) has become the most common cause of mitral valve (MV) surgery. MV repair is feasible in most patients with degenerative MR, and the freedom from reoperation is very high. However, a consistent number of patients develop significant functional tricuspid regurgitation (TR) following MV repair, and significant TR has been reported as being responsible for an increase in mortality late after MV surgery [1–6]. Accordingly, as recognition of the negative effect of functional TR after MV surgery has increased, surgical indications for tricuspid valve (TV) repair at the time of MV surgery have been extended to include not only the severity of TR but also dilatation of the tricuspid annulus [7–9]. However, the prognostic value of
this recommendation has not been prospectively evaluated. The standard surgical technique of TV repair for functional TR is tricuspid annuloplasty, which has a favorable effect on mortality in comparison with suture technique, such as De Vega's or Kay's technique [7,10–15]. There remains a debate, however, regarding size selection for the prosthetic ring in TV repair. Moreover, because of the changes in the tricuspid annular shape and size during the cardiac cycle, an established method for determining the optimal tricuspid annular size and motion is still lacking. Therefore, we conducted a prospective clinical study concerning patient selection and selection of a prosthetic ring size for TV repair, and clinical outcomes with and without TV repair for patients undergoing MV repair for severe MR. 2. Methods 2.1. Study population
⁎ Corresponding author at: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44122, USA. E-mail address: [email protected] (T. Kitai).
A total of 167 consecutive patients with severe MR who were scheduled for MV repair were prospectively included in this study from September 2007 to March 2010. Among
http://dx.doi.org/10.1016/j.ijcard.2016.10.056 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
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these patients, TV repair was indicated at the time of MV repair if they had at least one of the following conditions: (1) TR ≥ moderate, (2) history of right heart failure, defined as a significant lower extremity edema, pleural effusion or ascites requiring diuretics, (3) atrial fibrillation, and (4) pulmonary hypertension, defined as estimated right ventricular systolic pressure (RVSP) N 50 mm Hg. Patients who would require additional tricuspid procedures beyond ring annuloplasty were excluded from this study. According to these criteria, 100 patients (60%) required TV repair while 67 patients (40%) who did not have any of the aforementioned conditions were not indicated for TV repair. Among the 100 patients who required TV repair based on the criteria, 7 did not undergo TV repair. Therefore, we compared 93 patients with TV repair and 67 patients without TV repair in the perprotocol analysis. The CONSORT diagram shows our strategy for the patient selection (Fig. 1). This study was prospectively designed and approved by our Institutional Review Board, and all participants provided written informed consent.
2.2. Surgical procedures The procedures were performed with the use of mild hypothermic cardiopulmonary bypass with intermittent antegrade and/or retrograde cold blood cardioplegia for myocardial protection. Double venous cannulation was used. After establishment of cardiopulmonary bypass, cardiac arrest was obtained by infusion of cold blood cardioplegia. MV repair was performed using simplified and reproducible techniques as previously reported [16,17]. In brief, resection and suture were performed for prolapsed posterior leaflet, and the height of the remaining posterior leaflet was reduced to less than 15 mm using a sliding technique or folding procedure, if necessary. Chordal reconstruction with expanded polytetrafluoroethylene was performed to repair the anterior leaflet. Mitral ring annuloplasty was routinely performed using a flexible complete ring or a band. Intraoperative transesophageal echocardiography was routinely performed to evaluate residual regurgitation. During the Maze procedure, both right and left atrial appendages were excluded. The summary of the procedure for TV repair is illustrated in the Central Picture. The first stitch (2-0 braided suture) was made at the annulus of the anterior leaflet at the anterior– septal commissure, after which a horizontal mattress suture at the annulus of the septal leaflet was placed. The distance between the anterior and septal stitches was the same as the band size, and the circumferential length was three times the band size (Fig. 2). Plication was carefully measured from the antero-posterior commissure to the posteroseptal commissure. Half of the band corresponded to the anterior annulus and the other half to the posterior annulus and part of the septal annulus. A small RB1 needle was applied to prevent kinking of the band after implantation. Annular stitches along the anterior tricuspid leaflet corresponded to half of the band. Ten to twelve bites were required according to dilatation of the annulus. Constant circumferential length can be obtained in the same size of band. A flexible band (Tailor™, St. Jude Medical, St. Paul, MN, USA) was used in all the procedures for TV repair in this study. As the systolic tricuspid annulus area is reported as 3.9 cm2/m2 in normal subjects [18], patient's tricuspid circumferential length was estimated along with
each patient's body surface area (BSA). Therefore, we selected the size of the ring from four possible options (25, 27, 29, and 31 mm). 2.3. Echocardiographic evaluation and clinical outcomes Echocardiographic data were analyzed before surgery, at discharge following the surgery, and at 1, 3, and 5 years after surgery. Two-dimensional echocardiography and Doppler color-flow imaging were performed in all patients. TR severity was assessed in accordance with the criteria of the American Society of Echocardiography [19]. Color Doppler images were obtained in at least two orthogonal planes. Right ventricular systolic pressure was estimated using continuous-wave Doppler and the simplified Bernoulli equation of TR peak velocity [19]. The tricuspid annulus was reconstructed and measured by transthoracic real-time three-dimensional (3D) echocardiography before and after the surgery as previously reported [20]. The primary outcome measure was a composite of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate. The grade of TR was recorded at discharge following the surgery, and at 1, 3, and 5 years postoperatively. 2.4. Statistical analysis Categorical variables are shown as numbers and percentages and were compared using the chi-square test or Fisher's exact test, as appropriate. Continuous variables are expressed as mean and standard deviation or median and interquartile range. Based on their distribution, continuous variables were compared using Student's t-test or the Wilcoxon rank sum test. Two-sided P-values b 0.05 were considered statistically significant. A nonparametric repeated-measures analysis of variance (Friedman test) was used to test statistical differences in the TR grade with time among the groups, and the Wilcoxon signed-rank test was used to test statistical differences between each time group. The Kaplan–Meier method was used to estimate cumulative event-free survival, and differences in survival curves were compared using the log-rank test. All analyses were performed with the statistical software program JMP Pro 10.0.0 (SAS institute, Cary, NC, USA).
3. Results 3.1. Baseline patient characteristics and preoperative echocardiography The clinical features of the 167 patients enrolled are summarized in Table 1. There were 104 (62%) men and 63 (38%) women with a mean age of 59 ± 15 years. Transthoracic echocardiography was performed
Fig. 1. CONSORT diagram of the study patients.
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
T. Kitai et al. / International Journal of Cardiology xxx (2016) xxx–xxx
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Fig. 2. Representative illustration for tricuspid valve repair.
before surgery in all patients. The mean LV ejection fraction, LV enddiastolic dimension, and LV end-systolic dimension were 63 ± 9%, 55 ± 7 mm and 34 ± 8 mm, respectively. Atrial fibrillation was detected in 48 (29%) patients preoperatively and pulmonary hypertension was seen in 33 (20%) patients. Twenty-eight patients had severe heart failure symptoms before surgery. Baseline characteristics stratified according to whether or not patients underwent TV repair, for the intension-to-treat analysis are shown in Table 1. Patients with TV repair were associated with older age and a higher prevalence of severe heart failure symptoms and concomitant Maze procedure, as well as larger left atrial size and higher pulmonary artery systolic pressure. The tricuspid annulus diameter of patients without TV repair was significantly smaller than that of those with TV repair in both the diastolic (28.7 ± 5.1 vs 24.6 ± 3.5 mm, P b 0.001) and systolic phases (23.8 ± 4.7 vs 19.2 ± 3.0 mm, P b 0.001). 3.2. Surgical procedures MV reparative procedures included resection and suture for prolapsed posterior leaflet (n = 109), chordal reconstruction with GoreTex (CV-5) for anterior prolapse (n = 59), glutaraldehyde-treated autologous pericardial patch (n = 27), and ring annuloplasty (n = 163). Concomitant procedures included aortic valve replacement (n = 20), maze procedure (n = 52), and coronary artery bypass grafting (n = 14). MV procedures and concomitant procedures are summarized in Table 2. Mean BSA of the patients was 1.73 ± 0.16 m2; a 27-mm prosthesis was selected for 46 (49%) patients and a 29-mm prosthesis for 45
Table 1 Patient characteristics and preoperative echocardiographic indices.
Age, year, mean ± SD Male, n (%) NYHA functional class III or IV, n (%) Preoperative echocardiography LV ejection fraction, % LV end-diastolic dimension, mm LV end-systolic dimension, mm Left atrial dimension, mm Estimated PA systolic pressure, mmHg Tricuspid annular diameter in diastole Tricuspid annular diameter in systole Indications for tricuspid annuloplasty, n (%) Tricuspid regurgitation (≥moderate) Atrial fibrillation Pulmonary hypertension History of right heart failure
(48%) patients. The diastolic diameter of the tricuspid annulus was significantly decreased after TV repair (28.7 ± 5.1 vs 19.9 ± 3.6 mm, P b 0.001), similar to the systolic diameter of the tricuspid annulus in patients without TV repair (19.9 ± 3.6 vs 19.2 ± 3.0 mm, P = 0.72).
3.3. Outcomes and recurrent or development of tricuspid regurgitation after mitral valve surgery The median follow-up period was 6.5 (interquartile range: 5.2 to 7.2) years after MV surgery. During follow-up there were 4 deaths and 3 re-do surgeries, and 8 patients developed recurrence of severe MR. A total of 26 patients showed progression or recurrent TR ≥ moderate, including 4 patients with severe TR. The TR grade at discharge and at 1, 3, and 5 years, respectively, was 0.3 ± 0.5, 0.5 ± 0.6, 1.0 ± 0.7, and 0.8 ± 0.9 in patients with TV repair and 0.4 ± 0.5, 0.4 ± 0.5, 1.1 ± 0.5, and 0.9 ± 0.7 in those without TV repair (Fig. 3). Freedom from recurrence or progression to TR ≥ moderate at 1, 3 and 5 years after MV surgery was 91, 83, and 83% in patients with TV repair and 92, 85, and 84% in those without TV repair, respectively (P = 0.82). The Kaplan–Meier survival curve showed no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR ≥ moderate (P = 0.46, Fig. 4). In 33 patients who had preoperative pulmonary hypertension (RVSP: 58.7 ± 9.9 mm Hg), RVSP was
Table 2 Surgical procedures, and tricuspid prosthesis selection.
TV repair (+) (n = 100)
TV repair (−) (n = 67)
P
64 ± 14 57 (57) 22 (22)
53 ± 13 47 (70) 6 (9)
b0.001 0.10 0.03
62 ± 9 54 ± 8 34 ± 8 49 ± 7 45 ± 13 28.7 ± 5.1 23.8 ± 4.7
65 ± 9 55 ± 7 33 ± 7 42 ± 7 34 ± 6 24.6 ± 3.5 19.2 ± 3.0
0.06 0.48 0.50 b0.001 b0.001 b0.001 b0.001
59 (59) 48 (48) 33 (33) 59 (59)
0 (0) 0 (0) 0 (0) 0 (0)
b0.001 b0.001 b0.001 b0.001
TV = tricuspid valve; NYHA = New York Heart Association; LV = left ventricular; PA = pulmonary artery.
Mitral valve procedures Resection and suture of PML Chordal reconstruction with ePTFE Pericardial patch Mitral ring annuloplasty Concomitant surgical procedures Coronary artery bypass graft Aortic valve replacement/repair Maze Size of tricuspid prosthesis 25 mm 27 mm 29 mm 31 mm Postoperative echocardiography Tricuspid annular diameter in diastole Tricuspid annular diameter in systole
TV repair (+) (n = 93)
TV repair(−) (n = 67)
P
65 (70) 36 (39) 14 (15) 90 (97)
44 (66) 23 (34) 13 (19) 66 (99)
0.61 0.57 0.52 0.64
10 (11) 11 (12) 47 (51)
4 (6) 9 (13) 5 (7)
0.40 0.47 b0.001
1 (1) 46 (49) 45 (48) 1 (1)
– – – –
– – – –
19.9 ± 3.6 15.1 ± 2.9
23.1 ± 3.8 17.8 ± 3.0
b0.001 b0.001
TV = tricuspid valve; PML = posterior mitral leaflet; ePTFR = expanded polytetrafluoroethylene.
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
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Fig. 3. Recurrence or progression of tricuspid regurgitation over time after mitral valve surgery.
significantly decreased at discharge (33.5 ± 7.1 mm Hg) and remained practically unchanged 1-year (36.4 ± 11.9 mm Hg) and 3-year after surgery (26.1 ± 12.9 mm Hg). 4. Discussion In this study, we assessed the long-term outcomes of patients who underwent MV repair with and without TV repair. The selection of patients for TV repair was based on the criteria listed in the Study Population section, and selection of the appropriate size of annuloplasty ring was based on patient's BSA. TR recurrence was acceptable according to our strategy, as was new development of TR in patients without TV repair. Functional TR was historically considered to be a benign disease that would disappear once MR had been treated. However, increasing evidence has shown that TR does not regress spontaneously, and may even develop and worsen over time in patients not undergoing TV repair at the time of MV surgery [1,6,21]. Therefore, TV repair accompanying MV surgery has recently become increasingly common, even if TR is not severe but when tricuspid annulus is dilated [7,8,19,22]. Given that surgical correction of MR alone does not correct tricuspid annular dilatation, such dilatation, if present, is progressive and, although it may not be accompanied by TR initially, eventually leads to the development
Fig. 4. The Kaplan–Meier estimates of freedom from all-cause death, re-do mitral and/or tricuspid surgery, and recurrence or progression of tricuspid regurgitation of moderate extent or worse.
and worsening of TR [7]. In addition, as functional TR after MV repair is associated with poor survival and functional status [13,23–26], TV repair regardless of the absolute grade of TR at the time of MV surgery could theoretically halt the progression of TR and be associated with a better prognosis. However, there is still insufficient scientific evidence for prophylaxis in cases of minimal or absent TR, even in cases with tricuspid annular dilatation. The normal tricuspid annulus has a nonplanar or saddle-like structure with distinct high points located anteriorly and posteriorly, and low points located septally and laterally [18,27]. In patients with functional TR, the annulus becomes dilated, flatter, and more circular, with a decreased mediolateral-to-anteroposterior ratio [28]. Thus, reported abnormality of the tricuspid annulus has included not only dilatation, but also deformity of the saddle-shaped annulus [18,20,28]. Moreover, because the shape and size of the tricuspid annulus are dynamic during the cardiac cycle, the reproducible and reliable measurement of the tricuspid annulus and the diagnosis of tricuspid annular dilatation remain difficult. Although 3D echocardiography provides additional data on TV annulus beyond 2D echocardiography, accurate assessment of TV annulus can still be difficult because of its asymmetric saddle shape and movement during the cardiac cycle [18,20,28,29]. Therefore, clinical conditions that represent tricuspid annular dilation should be taken into account during the decision-making of process for TV repair. In the current study, we included history of right heart failure, pulmonary hypertension, and atrial fibrillation as conditions suggesting tricuspid annular dilatation. Pulmonary hypertension has been shown to correlate approximately with severity of functional TR [29]. Atrial fibrillation has been shown to be associated with TR progression after MV surgery, in addition to annular dilatation and pulmonary hypertension [8]. Pulmonary hypertension and atrial fibrillation are well known as risk factors for the development of functional TR [2]. We included these conditions that require TV repair regardless of TR grade. Moreover, a clinical history of right heart failure is strongly suspected to lead to a more than moderate TR associated with annulus dilatation. As little is known regarding the normal and pathological size of the tricuspid annulus, we selected the size of the ring designed for a normal-sized tricuspid annulus in systole according to the patient's BSA [18]. Another challenge is to test the rationale for the strategy that TV repair is not indicated unless the tricuspid annulus is dilated. Little is known regarding whether patients without tricuspid annular dilatation still go on to develop TR during follow-up after MV surgery. Because the absence of annular dilatation at the time of MV surgery does not guarantee against future annular dilatation or future development of functional TR, a question arises concerning whether TV repair should routinely be performed in all cases of MV surgery regardless of tricuspid annular dilatation or TR grade. In the current study, TV repair was not indicated in 67 patients (40%) who did not have any conditions including (1) TR ≥ moderate, 2) history of right heart failure, (3) pulmonary hypertension, and (4) atrial fibrillation. Patients who did not undergo TV repair had 84.8% free rate from significant TR 5 years after surgery. Our data support the concept that prophylactic TV repair is not required when the tricuspid annulus is not dilated. In addition, although it is reported that concomitant TV repair did not significantly increase the preoperative mortality and morbidity [30], TV repair is not an entirely benign intervention. Therefore, we do not think there is sufficient justification to extend the liberal use of TV repair to all the patients undergoing MV surgery. However, clinician should remain aware of some patients who develop late TR despite not showing any of the indications for TV repair at the time of MV surgery. The main limitation of the present study is that it was not a randomized comparison of TV repair in patients with tricuspid annular dilatation. A randomized study is needed to investigate whether TV repair can improve outcome in patients who had TV annular dilation. However, it may raise some ethical difficulties because of the current guidelines recommendation for TV repair. Second, TR grade was not quantified in this study, and semi-quantitative measurement of TR severity based on TR
Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056
T. Kitai et al. / International Journal of Cardiology xxx (2016) xxx–xxx
jet area was used. Nevertheless, semi-quantitative measurement of TR is widely used in clinical practice. Third, because echocardiographic followup was incomplete, the potential for under- or overestimation of the incidence of recurrent symptomatic severe TR should be acknowledged. We did not investigate right ventricular function and detailed geometric changes in right ventricular shape. Finally, the study was performed in a single center, which led to limitations in the generalization of results. 5. Conclusions Patient selection for TV repair based on clinical signs representing tricuspid annular dilatation, rather than exact measures of tricuspid annulus, was feasible at the time of MV repair. Reduction annuloplasty for functional TR targeting a normal systolic size of tricuspid annulus in accordance with BSA was a simple and reproducible procedure. Acknowledgement of grant support None. Conflict of interest statement None. References [1] A. Porter, Y. Shapira, M. Wurzel, J. Sulkes, M. Vaturi, Y. Adler, G. Sahar, A. Sagie, Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation, J. Heart Valve Dis. 8 (1999) 57–62. [2] H. Song, M.J. Kim, C.H. Chung, S.J. Choo, M.G. Song, J.M. Song, D.H. Kang, J.W. Lee, J.K. Song, Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery, Heart 95 (2009) 931–936. [3] J.J. Kwak, Y.J. Kim, M.K. Kim, H.K. Kim, J.S. Park, K.H. Kim, K.B. Kim, H. Ahn, D.W. Sohn, B.H. Oh, Y.B. Park, Development of tricuspid regurgitation late after leftsided valve surgery: a single-center experience with long-term echocardiographic examinations, Am. Heart J. 155 (2008) 732–737. [4] C. Izumi, M. Miyake, S. Takahashi, H. Matsutani, S. Hashiwada, K. Kuwano, H. Hayashi, S. Nakajima, M. Nishiga, K. Hanazawa, J. Sakamoto, H. Kondo, T. Tamura, K. Kaitani, K. Yamanaka, Y. Nakagawa, Progression of isolated tricuspid regurgitation late after left-sided valve surgery. Clinical features and mechanisms, Circ. J. 75 (2011) 2902–2907. [5] A.B. Goldstone, J.L. Howard, J.E. Cohen, J.W. MacArthur Jr., P. Atluri, J.N. Kirkpatrick, Y.J. Woo, Natural history of coexistent tricuspid regurgitation in patients with degenerative mitral valve disease: implications for future guidelines, J. Thorac. Cardiovasc. Surg. 148 (2014) 2802–2809. [6] A. Matsunaga, C.M. Duran, Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation, Circulation 112 (2005) I453–I457. [7] G.D. Dreyfus, P.J. Corbi, K.M. Chan, T. Bahrami, Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann. Thorac. Surg. 79 (2005) 127–132. [8] R.A. Nishimura, C.M. Otto, R.O. Bonow, B.A. Carabello, J.P. Erwin 3rd, R.A. Guyton, P.T. O'Gara, C.E. Ruiz, N.J. Skubas, P. Sorajja, T.M. Sundt 3rd, J.D. Thomas, 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, J. Am. Coll. Cardiol. 63 (2014) 2438–2488. [9] V.P. Harjola, A. Mebazaa, J. Celutkiene, D. Bettex, H. Bueno, O. Chioncel, M.G. CrespoLeiro, V. Falk, G. Filippatos, S. Gibbs, A. Leite-Moreira, J. Lassus, J. Masip, C. Mueller, W. Mullens, R. Naeije, A.V. Nordegraaf, J. Parissis, J.P. Riley, A. Ristic, G. Rosano, A. Rudiger, F. Ruschitzka, P. Seferovic, B. Sztrymf, A. Vieillard-Baron, M.B. Yilmaz, S. Konstantinides, Contemporary management of acute right ventricular failure: a statement from the heart failure association and the working group on pulmonary circulation and right ventricular function of the european society of cardiology, Eur. J. Heart Fail. 18 (2016) 226–241. [10] P.B. Bertrand, G. Koppers, F.H. Verbrugge, W. Mullens, P. Vandervoort, R. Dion, D. Verhaert, Tricuspid annuloplasty concomitant with mitral valve surgery: effects on right ventricular remodeling, J. Thorac. Cardiovasc. Surg. 147 (2014) 1256–1264.
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Please cite this article as: T. Kitai, et al., Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgita..., Int J Cardiol (2016), http://dx.doi.org/10.1016/j.ijcard.2016.10.056