Tricuspid regurgitation secondary to mitral valve disease

Cardiovascular Surgery, Vol. 9, No. 4, pp. 369–377, 2001  2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967-2109/01 $20.00

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Tricuspid regurgitation secondary to mitral valve disease: Tricuspid annulus function as guide to tricuspid valve repair Tiziano Colombo, Claudio Russo, Guglielma Rita Ciliberto, Marco Lanfranconi, Giuseppe Bruschi, Salvatore Agati and Ettore Vitali Department of Cardio-Thoracic Surgery ‘A. De Gasperis’, Ospedale Niguarda Ca’Granda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy Methods. A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter >21 mm/m2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. Results. Hospital mortality was 2.0% (CL 0.3–3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25±15.9). Three late deaths occurred (6.1% CL 2.8–9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9–93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as ‘negative late results’: persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of >25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the ‘preoperative fraction shortening of the tricuspid annulus’ (P = 0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% (P = 0.0001). Conclusions. The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (>21 mm/m2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.  2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: tricuspid insufficiency, tricuspid annulus function, echocardiography

Introduction In patients with mitral valve disease, right ventricle (RV) failure associated with severe involvement of the tricuspid valve represents an advanced stage of

Correspondence to: Tiziano Colombo MD. Tel: +39-02-64442565; Fax: +39-02-64442566; e-mail: [email protected]

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heart disease which has a significant and decisive effect on its natural and postsurgical course both in terms of mortality and of early and late complications [1]. Also in our experience, functional tricuspid insufficiency has been identified as a risk factor of hospital mortality after mitral valve replacement (MVR) [2], and untreated severe tricuspid regurgitation (tricuspid regurgitation) is an important factor in persistent reduced cardiac output and poor func369

Tricuspid regurgitation and mitral valve disease: T. Colombo et al.

tional outcome [1]. The relationship among tricuspid regurgitation, right ventricle’s failure degree, and changes in pulmonary vascularization are hitherto not well defined. Therefore the evaluation and treatment of secondary tricuspid regurgitation continues to be a major problem in the surgical decision-making process [3, 4]. As recently reported by Duran, ‘...these papers highlight our ignorance on the tricuspid valve. The challenge remains’ [5]. In agreement with other authors [6–9], who have proposed a two-dimensional echocardiography analysis of the tricuspid annulus function and color flow imaging of severity of the tricuspid regurgitation as a guide to tricuspid valve repair, we prospectively studied 50 patients with mitral valve disease and secondary tricuspid insufficiency. The preoperative evaluation, the surgical indication and the postoperative evaluation were strictly standardized. The main goal of the research of preoperative diagnostic parameters was to forecast the evolution of secondary tricuspid disease and particularly of right ventricle cardiopmyopathy. The codification of these parameters, different from the simpler semiquantitative evaluation of tricuspid regurgitation, could be helpful for a better definition of the surgical indication and for a more exact evaluation of long term prognosis of this group patients with mitral valve disease and secondary tricuspid regurgitation.

temic venous hypertension the following hallmarks: congestive liver enlargement, jugular venous engorgement, peripheral edemas, ascites. Medium-high dose diuretic therapy has been defined as the need of daily furosemide assumption >50 mg. Furthermore, the laboratory data related to liver insufficiency due to congestive heart failure were evaluated, particularly intrahepatic colestasis (gammaGT and alcaline phosphatase) and dysfunction of liver protein synthesis (prothrombin activity, albuminemia, cholinesterase). The pulmonary hypertension grade was defined according to the restrictive parameters adopted in our department [11]: we have considered as mild, moderate and severe pulmonary hypertension, respectively, the values of 30–45 mmHg, 45–70 mmHg and >70 mmHg. The clinical characteristics of the patients are depicted in Tables 1 and 2. Echocardiographic diagnostic criteria

Patients and methods

For all patients the preoperative evaluation of tricuspid insufficiency has been accomplished by matching the clinical features and the clinical history with the echocardiographic findings. An echocardiographic evaluation was done just before a patient’s discharge and at follow-up. Echocardiographic evaluation was carried out through transthoracic and, whenever indicated, transesophageal Echo+Doppler approach [12]. The following Echo-2-D and Colour-Doppler parameters were evaluated by:

This study includes 50 patients affected by postrheumatic mitral disease (with prevalent stenosis) and secondary tricuspid regurgitation who underwent elective surgery from January 1995 to December 1998 at the Angelo De Gasperis Cardiac Surgery Division in Milan. All the patients were strictly selected and included in the study on the basis of the valve disease type and on the basis of the onset of tricuspidalization of mitral disease. The tricuspid regurgitation was defined as secondary in presence of morphologically normal tricuspid leaflets with tricuspid annulus enlargement of variable degree or in presence of the right ventricle dilatation together with dysfunction of the tricuspid valve’s supporting structures and miscoaptation of its leaflets [10]. In this study patients were excluded whose tricuspid regurgitation had been judged as organic because of the presence of associate tricuspid stenoses and/or other alterations of the valve apparatus, evaluated by echocardiografy and confirmed during the surgical inspection. Patients were also excluded with other kinds of extra-cardiac disease potentially able to interfere with a correct preop and postop evaluation of tricuspid disease. We considered as sign of right-sided heart failure and sys-

앫 Mitral valve area: both planimetric and derived by mitral pressure half time 앫 Presence and degree of mitral regurgitation: jet length and jet area at its origin 앫 Left ventricle (LV) end-diastolic diameter (EDD) and systolic diameter (ESD) inter-ventricular septum (IVS) and free wall thickness 앫 Left atrium (LA) end-systolic diameter (anterior–posterior) 앫 Left ventricle end-diastolic (EDV) and end-systolic volume (ESV) from the four chambers view using the prolate ellipsoid model ‘Simpson’s Rule Method’ 앫 Left ventricle (LV) ejection fraction (E.F.) based on two dimensional Echo-2-D measuring enddiastolic and end-systolic volumes 앫 Tricuspid’s annular ring diameter and its fractional shortening 앫 Right atrium (RA) end-systolic diameter 앫 Planimetric right atrium area from four chambers view 앫 Right ventricle (right ventricle) end-diastolic diameter and right ventricle systolic function describing changes in local contraction by qualitative method 앫 Preoperatively were evaluated tricuspid valve

370

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Tricuspid regurgitation and mitral valve disease: T. Colombo et al. Table 1

Clinical characteristics — I (50 patients)a No

Male Female Age Duration of mitral disease (yr) Duration of symptoms (yr) Previous cardiac surgery (pts) on ECC closed commissurotomy Liver dysfunction intrahepatic colestasys synthesis alteration

Min–max

Mean±SD

9 41

% 18.0 82.0

31–71 10–55 1–40

59.4±7.7 32.9±11.4 14.8±8.7

32* 8 26

64.0 16.0 52.0

33 10

66.0 20.0

a

SD=standard deviation; pts=patients; yr=years; ECC=extracorporeal circulation; *Two patients with two previous cardiac surgery

Table 2

Clinical characteristics — II (50 patients)a No

Electrocardiogram Sinus rhythm Atrial fibrillation RVH signs Cardio-thoracic ratio NYHA class II III IV Signs of congestive status Chronic congestive failure Ascites Previous APE Pulmonary hypertension Absent Mild Moderate Severe

Min–max

Mean±SD

2 48 15

%

4.0 96.0 30.0 0.48–0.70

0.60±0.06

3 38 9 34 8 3 8

6.0 76.0 18.0 68.0 16.0 6.0 16.0

8 16 18 8

16.0 32.0 36.0 16.0b

a

VMR=mitral valve replacement;Tr=tricuspid valve; RVD=right ventricle hypertrophia; APEe=acute pulmonary edema Incidence non significantly different (P = 0.33) in comparison with pts with VMR without Tr disease (11.6%)

b

leaflets’ morphology and motion; postoperatively the motion of the prosthesis 앫 By Color-Doppler technique were evaluated by: 앫 Prosthetic valve area and peak and mean gradient 앫 Other valve’s gradient 앫 The peak systolic gradient between right ventricle and right atrium estimated from the peak velocities of the regurgitation jet to estimate pulmonary artery systolic pressure, adding a fix value of 10 mmHg 앫 Using Color-Doppler were evaluated the presence and jet size of valve regurgitation Preoperative echocardiographic findings of the patients are depicted in Table 3. CARDIOVASCULAR SURGERY

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Intraoperative data All patients underwent mitral valve replacement (MVR): in 47 cases with mechanical prosthesis and in three with porcine bioprosthesis. According to same authors [7, 8], all patients with echocardiographic measurement of diameter of tricuspid annulus >21 mm underwent tricuspid annuloplasty, regardless of the semiquantive evaluation of tricuspidal regurgitation. In order to evaluate the accuracy of preoperative echocardiographic evaluation and its relationship with the surgical findings, in all patients a direct surgical evaluation of the tricuspid valve and a direct measurement of tricuspid annulus was performed: the size of tricuspid annulus ranged from 25 to 60 mm (mean 46.5±7.8mm). 371

Tricuspid regurgitation and mitral valve disease: T. Colombo et al. Table 3

Preoperative echocardiographic findings (50 patients) No

Mitral valve Area (cm2) Max gradient (mmHg) Mean gradient (mmHg) Left atrium (mm) Left ventricle Diastolic diameter (mm) Systolic diameter (mm) Ejection fraction Right atrium (area) (cm2) Diastolic right ventricle diameter (mm) Systolic pulmonary pressure (mmHg) Tricuspid annulus diameter (mm) Tricuspid annulus % shortening Jet area(cm2) Tricuspid insufficiency Mild Mild-moderate Moderate Moderate-severe Severe

Min–max

Mean±SD

0.5–1.5 14–32 3–17 35–88

1.0±0.3 17.7±6.3 10.1±4.2 57.7±11.6

41–64 21–46 30–73 15–47 19–57

49.1±5.2 33.5±6.5 56.2±8.9 30.4±9.1 34.0±8.5

25–90

48.8±15.5

27–54 7–47 1.5–22

40.8±5.9 24.9±10.0 9.0±5.9

6 3 10 7 24

According to the above reported criteria, a De Vega annuloplasty procedure was performed in 33 out of the 50 patients enrolled in the study (66.0%): 23 with a severe tricuspid regurgitation, 5 with a moderate-severe tricuspid regurgitation and 5 with a moderate tricuspid regurgitation. Due to their clinical and emodynamic features and because of a mismatch between the different values of tricuspid annulus diameter evaluated preoperatively by two dimensional Echo and intraoperatively by direct vision, five patients did not undergo any procedure on the tricuspid valve; out of the five, the echocardiographic the indexed size of tricuspid annulus was 23 mm (2 cases), 24, 25 and 26 mm/ m2 respectively. Follow up The patients were followed up from January to December 1999 in an outpatient department by clinical visit, ECG, chest X-rays, and by Echo Color Doppler performed in the hospital Echo Lab. Statistical methods The data, collected in the computerized archive of patients undergoing cardiac valve surgery at De Gasperis Cardiac Division, were expressed in terms of absolute values with the relative average (± Standard Deviation — SD) and/or percentage values with the relative confidence limit at 70% (C.L.70%). Continuous variables were compared with impaired t-testing or non-parametric tests as appropriate. Categorical variables were compared with chi-square test with Yates correction when needed. 372

%

12.0 6.0 20.0 14.0 48.0

A residual significant tricuspid regurgitation (moderate, moderate-severe, severe) at late echocardiographic follow-up and a concomitant systemic congestive status requiring a furosemide intake >25 mg a day was considered as ‘negative late result’. All the preoperative variables were first studied individually by means of univariate analysis. The correlation coefficients of all the possible pairs of variables found to be significant on univariate analysis were then calculated in order to avoid the inclusion of similarly significant variables in the multivariate analysis. In the case of a significant correlation between a pair of variables (r>0.7), the inclusion of one of the variables was determined on the basis of an evaluation of the importance attributed to the data by the variables themselves. The variables which were found significant (P⬍ 0.05) or marginally significant (0.05⬍P⬍0.10) at univariate analysis were then inserted into a Cox regression analysis (proportional hazard model) [13]. Statistical analysis was performed by ‘Statistica for the Macintosh TM’, by StatSoft Inc., Tulsa [14].

Results Early results On the 10th postoperative day, 1 death (2% — C.L. 0.3–3.6) occurred due to low cardiac output syndrome in one patient affected by severe biventricular cardiomyopathy (preoperative LVEF 30%, severe CARDIOVASCULAR SURGERY

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right ventricle hypokinesis with shortening fraction of tricuspid anulus of 7%). In five patients [ 10.0% (C.L. 5.7–13.9)] occurred six non fatal postoperative complications: reoperation due to bleeding (four cases), slow rate atrial fibrillation which needed a pacemaker implant (one case), acute myocardial infarction (one case). All the surviving patients were discharged from hospital after a time ranging from 8 to 29 postoperative days (mean 15.8±6.3 days); just two patients [4.1% (C.L. 1.4–6.6)] showed signs of congestive heart failure which needed a middle-high dosage intake of diuretics. Regarding the size of tricuspid annulus, a significant correlation has been demonstrated (P = 0.0008) between the preoperative ecocardiographic findings and the direct evaluation in the operating room. On the contrary, regarding the grade of tricuspid regurgitation, no correlation has been demonstrated between the preoperative echocardiografic and intraoperative direct (by surgeon’s finger) evaluations. Furthemore, no correlation has emerged about the pulmonary artery systolic pressure between the preop echo and the intraop emodynamic evaluation. Late results The mean follow-up among was 25.3±15.9 months (range 3–49 months). Three late deaths [6.1% (C.L. 2.8–9.2)] occurred, after 12, 20 and 24 postoperative months respectively, because of acute myocardial infarction, prosthesis thrombosis and G.I. cancer. Among the 46 patients followed, no other mitral prosthesis related complications (embolism, bleeding, endocarditis, reoperation) occurred. Forty-two out of 46 patients followed (91.3% C.L. 84.9–93.8) were, at the time of postoperative followup, in I or II NYHA class. Four patients were in III NYHA class: one patient, with a preoperative left ventricle ejection fraction (LV EF) of 45% and a mild-moderate tricuspid regurgitation, developed a left ventricle cardiomyopathy (echo LV EF=25%) with a mild persistent tricuspid regurgitation; one patient reported a worsening functional status after an episode of pulmonary embolism following a thromboflebitis of lower limbs, on the third postoperative month; two patients who underwent tricuspid annuloplasty with preoperative severe tricuspid regurgitation and enlarged and hypokinetic right ventricle, were recently admitted to hospital because of congestive heart failure and, at present, they need high dose (HD) furosemide intake. Six patients, in postop II NYHA class, have showed at follow-up an worsening venous engorgement requiring an progressive increase of furosemide intake after the discharge from the hospital. In total, after the clinical and the echo follow-up in CARDIOVASCULAR SURGERY

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order to evaluate the tricuspid regurgitation, in eight patients (16.3% out of the discharged patients C.L. 10.9–21.1) the results has been considered as ‘negative late result’. Echo results The late echo results inherent to right heart are depicted in Table 4. In all the patients, the mitral prosthesis was correctly working: this is an indispensable premise to evaluate the presence of a persistent tricuspid regurgitation. The Echo showed a moderate tricuspid regurgitation in three cases and a moderate-severe tricuspid regurgitation in five cases. No severe tricuspid regurgitation was found. The grade of tricuspid regurgitation on the second echo evaluation appeared significantly related to the grade of tricuspid regurgitation found on the pre-discharge echo evaluation. The grade of tricuspid regurgitation changes in both groups of patients who underwent or who did not undergo tricuspid annuloplasty are depicted, respectively, in Tables 1 and 2. Among the 26 patients who underwent tricuspid annuloplasty with a preoperative moderate-severe or severe tricuspid regurgitation, 19 patients [73% (C.L. 61.6–79.1)] had mild or no postop tricuspid regurgitation., three patients [11.5%. (C.L. 5.2–17.0)] had mild-moderate postop tricuspid regurgitation, one patient [3.8%.(C.L. 0.5–6.9)] moderate tricuspid regurgitation and three patients [11.5%.(C.L. 5.2–17.0)] moderate-severe tricuspid regurgitation. Among the patients who did not undergo any tricuspid procedure, those patients with a mild or mild-moderate preop tricuspid regurgitation showed mild or no postop tricuspid regurgitation. In the group of eight patients with ‘negative late result’ (moderate-severe or severe postop tricuspid regurgitation), there was a moderate preop tricuspid regurgitation in two patients, a moderate-severe tricuspid regurgitation in one patient, severe in five patients. In the group of five patients with tricuspid annulus >21 mm/m2 that did not undergo tricuspid annuloplasty, two patients showed a persistent significant tricuspid regurgitation at the follow-up (negative late results). There was postop right ventricle hypokinesis in six out of ten patients with preop right ventricle hypokinesis; four of them had been classified as a ‘negative late result’. Statistical analysis, performed according to the Cox model, has identified as the only indipendent predictive factor for negative late result the variable ‘preoperative fractional shortening of the tricuspid annulus’ (P = 0.038). The poor late result incidence, in comparison with that variable, was 57.1% in patients with fractional shortening 25% while no 373

Tricuspid regurgitation and mitral valve disease: T. Colombo et al. Table 4

Late postoperative echocardiographic findings (relatively to right heart chambers) (46 patients) No

Right atrium (area) (cm2) RV diastolic diameter (mm) Systolic pulmonary pressure (mmHg) Tricuspid annulus diameter (mm) Tricuspid annulus % shortening Jet area (cm2) Tricuspid insuficiency Absent Mild Mild-moderate Moderate Moderate-severe

Min–max

Mean±SD

11–40 18–40 20–60

25.2±8.4 31.6±5.1 37.8±8.7

20–46 17–37 1.7–9.2

31.5±5.9 27.3±5.9 4.9±2.8

10 22 6 3 5

poor late result (0%) occurred among patients with fractional shortening >25% (P = 0.0001). Discussion The lack of precise, easily applicable and reproducible diagnostic criteria to assess the severity of tricuspid regurgitation in the past years has made it very difficult in selecting patients undergoing surgery for tricuspid insufficiency during or after the surgery for mitral disease. The tricuspid late evaluation after surgery has sometimes been difficult. Several pathways have been proposed to evaluate the tricuspid regurgitation: right atrial curve analysis, right ventriculography, radioisotope angiography, echocardiography with contrast. Wong et al. [6] reported the good sensibility of Echo Color Doppler in order to assess the grade of tricuspid regurgitation on the basis of extension of backward jet; this way, they identified preoperatively the patients who needed surgical treatment, with a 73% concordance to direct surgical evaluation. An even better assessment of patients who need tricuspid annuloplasty was achieved by Chopra [7] and Lambertz [8] by means of the jet area/right atrium ratio and tricuspid annulus diameter. In other studies [15], the size of the tricuspid annulus and, particularly, its changes during systole and diastole have been demonstrated to be important for a correct preoperative evaluation. In agreement with these authors, we believe that Echo Doppler/Color Doppler has great sensitivity and specificity so that it can be considered the elective approach in order to evaluate tricuspid involvement in patients with mitral valve disease. In our series, all the Echo variables above reported have been considered, by an accurate pre- and postoperative evaluation, we screened an homogeneous group of patients to follow up. The analysis of our series confirms the results of our previous study [1]: the subgroup of patients with mitral disease and secondary functional tricuspid involvement who underwent mitral valve replace374

%

21.8 47.8 13.0 6.5 10.9

ment have reported a clinical history of worsening functional classes but without episodes of pulmonary edema, frequent episodes of congestive heart insufficiency and associated organ dysfunction (intrahepatic colestasys), and significant heart volume increase. In this group of patients neither the EKG findings suggestive of right ventricle impairment (just 30% of patients) nor the pulmonary hypertension (absent or mild in 42.5% of cases) has appeared signifucant. The absence of episodes of pulmonary edema in these patients is indication of a lower pulmonary pressure; due to tricuspid incompetence, the right ventricle is allowed to unload itself also ejecting in a low pressure room, i.e. the right atrium. This is the reason why, according to our previous studies [1, 11, 16], the pulmonary hypertension has not resulted a predictive factor either for tricuspid involvement in mitral valve disease or for the reappearance of tricuspid insufficiency in patients with mitral prosthesis. The systolic PAP has not been significantly different between the patients of this study and the patients with mitral disease alone (P = 0.33) (Table 2). Furthermore, the systolic PAP has not been significantly different among patients with different grade of tricuspid regurgitation (PAP 49±17 mmHg in patients with severe tricuspid regurgitation and 51±10 mmHg in patients with mild tricuspid regurgitation) (P = 0.86). Recently, other authors [17, 18] found, in their series of patients who had undergone percutaneous mitral valvuloplasty, no correlation between PAP and grade of tricuspid regurgitation. The age of a patient and a long lasting clinical history (the latter, probably, causing an irreversible structural deterioration of the right ventricle) has demonstrated as the most important predictive factor for the evolution of tricuspid regurgitation after mitral valve replacement. The surgical evaluation of tricuspid regurgitation by finger assessment through the right appendage is no longer considered reliable; also the emodynamic CARDIOVASCULAR SURGERY

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intraoperative findings, more often influenced by anesthesia, have not appeared in relation to the preoperative Echo findings. On the other hand, the echo evaluation was definitely reliable for the sizing of tricuspid annulus and it correlated significantly with the surgeon’s intraoperative evaluation. Beyond the early and late mortality rate, also the analysis of the functional recovery is very interesting. The grade of functional improvement after surgery, according to our previous report [16], aligns with that of other greater series [19, 20]. The clinical and emodynamic advantage following the tricuspid annuloplasty is attributable to the increase of the right cardiac output as well to the decrease of the systemic venous engorgement [21]: both of these emodynamic variations are responsible for the reduction in hospital mortality and improvement of quality of life after discharge. On the other hand, after a correct and definitive correction of the mitral disease, a severe pre-existing or a residual tricuspid regurgitation could be the cause of the absence of postoperative functional improvement besides the increasing need for high doses of diuretic. According to other authors [7–9], the choice to correct the tricuspid regurgitation on the basis of indexed size of the tricuspid annulus (ⱖ21 mm/m2) showed great clinical relevance. In 83.9% of a group of 31 patients who underwent tricuspid procedure, the late follow up has demonstrated the absence of residual tricuspid regurgitation or a residual tricuspid regurgitation of mild or mild-moderate grade (Figure 1). In the group of patients who did not

Figure 1 Grade of TR changes; 31 patients operated on for MVS+tricuspidannuloplasty

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undergo tricuspid correction, two patients out of three with residual moderate or moderate-severe tricuspid regurgitation had tricuspid annulus >21 mm/m2, and the tricuspid regurgitation was not treated according to the study protocol (Figure 2). Our statistical analysis has demonstrated the shortening fraction of the tricuspid annulus alone as preoperative risk factor for late negative result (P = 0.038). This variable is the expression of the right ventricle cardiomyopathy in patients with a poor prognosis; the existence of right ventricle cardiomyopathy is confirmed also by the presence of the ‘right ventricle hypokinesia’ at the univariate analysis. The nomogram generated from the solution of the multivariate equation for these two risk factors for late negative result clearly shows the effect of low tricuspid annulus systolic shortening fraction and right ventricle hypokinesia (Figure 3). A good right ventricle kinesis and the shortening capacity of the tricuspid annulus have a greater predictive power than the preoperative sizing of the tricuspid annulus. One of the three patients who did not undergo tricuspid annuloplasty and with a negative late result, had showed a severely low preop. tricuspid annulus shortening fraction but with normal tricuspid annulus size. In cases without right ventricle cardiomyopathy, after the annuloplasty, the tricuspid annulus also seemed to keep a pretty normal size in case of preoperative significant oversize. For the surgical treatment of the functional tricuspid regurgitation, several conservative methods have been proposed (ring annuloplasty, De Vega annuloplasty, vanishing annuloplasty [22]). Due to the

Figure 2 Grade of TR changes; 15 patients operated on for isolated MVS

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Tricuspid regurgitation and mitral valve disease: T. Colombo et al.

Figure 3 Nomogram of a solution to the multivariate equation for risk factors for late negative result shows the effect of low percent annular shortening and of right ventricular systolic dysfunction on the probability of significant recurrent tricuspid regurgitation. (Defined values of the independent variables: AS 15 or 30% and right ventricle hypokinesia 0 or 1). AS=annular shortening; RV=right ventricle

high incidence of valve related complications and to the risk of acute dysfunction of the right ventricle after the sudden elimination of the regurgitation from the right ventricle toward the lower pressure right atrium, the decision to replace the tricuspid valve should be considered very carefully. Considering our results, we do not accept the surgical strategy that would relate the type of tricuspid surgery to the grade of pulmonary vascular resistence (always reduced after mitral valve procedure [11]), or to the severity of tricuspid regurgitation. The correct choice should be the result of a precise evaluation of the grade right ventricle myocardiopathy. According to other authors [3, 4, 20], in most of the cases, the De Vega annuloplasty may be an effective solution for the treatment of the secondary tricuspid regurgitation. Faced with significant right ventricle impairment, as reported by Conh [21] and according to the patho-physiologic presuppositions for the treatment of the mitral insufficiency in case of chronic cardiac insufficiency [23], the rigid ring annuloplasty may give better late results and it should be able to improve the post surgical course of this disease. In order to continue the perspective study of the secondary tricuspid regurgitation, we will choose this surgical option in cases with annular shortening fraction ⬍25%.

Conclusions The causes of the tricuspid regurgitation secondary to mitral disease are not well known. The clinical evolution of the tricuspid regurgitation seems to be related more to the ability of adapting the right ventricle than to the presence of pulmonary hypertension [1, 11, 16–18]. In patients with secondary tricuspid regurgitation, the development of right ventricle myocardiopathy seems to be the result of several factors (age, duration of clinical history, issue 376

of rheumatic carditis) all of them possibly able to determine the appearance and evolution of the disease. In most of cases, after correction of the mitral disease, the untreated mild tricuspid regurgitation decreases or does not increase [1, 22]. For the secondary tricuspid regurgitation with significant regurgitation due to annulus dilatation (> 21mm/m2), there is surgical indication at the time of mitral valve replacement. The treatment of the tricuspid regurgitation gives better late results because it reduces the venous congestive status [4]. The real prognostic value of the surgical treatment of the secondary tricuspid insufficiency has still to be evaluated. As a matter of fact, the surgical correction of tricuspid regurgitation has not been demonstrated to be capable of modifying substantially the late survival: the same late results [4, 24] have been reported for patients either with or without tricuspid annuloplasty or tricuspid valve replacement. The prognosis seems to be more likely related to the evolution of right ventricle myocardiopathy, of which the tricuspid regurgitation is only one of the clinical expressions. The knowledge of the right ventricle function echo parameters (kinesis, fraction shortening of the tricuspid annulus), before the mitral valve replacement, should be able to improve the prognostic evaluation of the patient with secondary tricuspid regurgitation in order to choose the best surgical option and to contrast as much as possible the evolution of right ventricle myocardiopathy.

References 1. Pellegrini, A., Colombo, T., Donatelli, F. et al., Evaluation and treatment of secondary tricuspid insufficiency. European Journal of Cardio-thoracic Surgery, 1992, 6, 288–296. 2. Donatelli, F., Vitali, E., Colombo, T. et al., Fattori di rischio di mortalita` nella sostituzione valvolare mitralica. In Cardiologia, ed. F. Rovelli. Librex, Milan 1988, pp. 487–492.

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Tricuspid regurgitation and mitral valve disease: T. Colombo et al. 3. De Paulis, R., Bobbio, M., Ottino, G.M. et al., The De Vega tricuspid annulplasty. Perioperative mortality and long-term follow-up. Journal of Cardiovascular Surgery, 1990, 31, 512–517. 4. McGrath, L.B., Gonzales-Lavin, L., Bailey, B.M. et al., Tricuspid valve operation in 530 patients. Twenty-five-year assessment of early and late phase events. Journal of Thoracic and Cardiovascular Surgery, 1990, 99, 124–133. 5. Duran, C.M.G., Editorial note: tricuspid valve replacement. Journal of Heart Valve Disease, 1996, 5, 168. 6. Wong, M., Matsumura, M., Kutsuzawa, S. et al., The value of Doppler echocardiography in the treatment of tricuspid regurgitation in patients with mitral valve replacement. Perioperative and two-year postoperative findings. Journal of Thoracic and Cardiovascular Surgery, 1990, 99, 1003–1010. 7. Chopra, H.K., Nanda, N.C., Fan, P. et al., Can two-dimensional echocardiography and Doppler color flow mapping identify the need for tricuspid valve repair? Journal of the American College of Cardiology, 1989, 14, 1266–1274. 8. Lambertz, H., Flachskampf, F.A. and Minale, C., Tricuspid regurgitation in patients with mitral valve disease — who needs tricuspid repair? (Abstract). Circulation, 1988, 78(Pt 2), 210. 9. Child, J.S., Improved guides to tricuspid valve repair: twodimensional echocardiographic analysis of tricuspid anulus function and color flow imaging of severity of tricuspid regurgitation. Journal of the American College of Cardiology, 1989, 5, 1275–1277. 10. Carpentier, A., Deloche, A. and Hanania, G., Surgical management of acquired tricuspid valve disease. Journal of Thoracic and Cardiovascular Surgery, 1974, 67, 53–65. 11. Merli, M., Amari, B., Grassi, M. et al., The course of extreme pulmonary hypertension in patients with mitral stenosis undergone mitral valve replacement. Il Cuore, 1988, V(3), 307–316. 12. Cooper, J., Fan, P.H., Chopra, H.K. et al., Conventional and color doppler assessment of right-sided valvular regurgitation. In Textbook of Color Doppler Echocardiography, ed. N.C. Nanda. Lea and Febiger, Philadelphia and London 1989, pp. 160–164. 13. Cox, D.R., Regression models and life tables. Journal of the Royal Statistical Society, 1972, 34, 187–220.

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AUGUST 2001 VOL 9 NO 4

14. Statistica for the Macintosh Statsoft Inc, Tulsa, OK 1994. 15. Sugimoto, T., Nakamura, K., Okada, M. et al., New quantitative method for evaluating tricuspid regurgitation. Journal of Cardiovascular Surgery, 1990, 31, 778–787. 16. Colombo, T., Quaini, E., Russo, C. et al., Tricuspidalizzazione dei vizi valvolari mitralici: come valutarla, come trattarla. In Cardiologia, eds F. Rovelli, C. De Vita and A. Moreo. Librex, Milan 1992, pp. 845–857. 17. Skudicky, D., Essop, M.R. and Sareli, P., Efficacy of mitral balloon valvotomy in reducing the severity of associated tricuspid valve regurgitation. American Journal of Cardiology, 1994, 73, 209–211. 18. Sagie, A., Schwammenthal, E., Palacios, I.F. et al., Significant tricuspid regurgitation does not resolve after percutaneous balloon mitral valvotomy. Journal of Thoracic and Cardiovascular Surgery, 1994, 108, 727–735. 19. Chidambaram, M., Abdulali, S.A., Baliga, B.G. et al., Long-term results of De Vega tricuspid annuloplasty. Annals of Thoracic Surgery, 1987, 43, 185–191. 20. Wei, J., Chang, C.Y., Lee, F.Y. et al., De Vega’s semicircular annuloplasty for tricuspid valve regurgitation. Annals of Thoracic Surgery, 1993, 55, 482–485. 21. Cohn, L.H., Tricuspid regurgitation secondary to mitral valve disease: when and how to repair. Journal of Cardiac Surgery, 1994, 9(Suppl.), 237–241. 22. Duran, C.M.G., Tricuspid valve surgery revisited. Journal of Cardiac Surgery, 1994, 9(Suppl.), 242–247. 23. Bach, D.S. and Bolling, S.F., Improvement following correction of secondary mitral regurgitation in end-stage cardiomyopathy with mitral annuloplasty. American Journal of Cardiology, 1996, 78, 966–969. 24. Cohen, S.R., Sell, J.E., McIntosh, C.L. et al., Tricuspid regurgitation in patients with aquired chronic, pure mitral regurgitation: nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. Journal of Thoracic and Cardiovascular Surgery, 1987, 94, 488–497. Paper accepted 1 December 2000

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