In mitral valve surgery, tricuspid valve repair stunts regurgitation progression
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In patients who had mitral valve surgery but also tricuspid regurgitation or tricuspid annular dilation, performing concomitant tricuspid valve repair lowered risk for progression of tricuspid regurgitation, researchers reported.
For the CTCA-MVS trial, researchers randomly assigned 401 patients (mean age, 67 years; 75% men) undergoing mitral valve surgery for mitral regurgitation who had moderate tricuspid regurgitation or no/trace/mild tricuspid regurgitation plus tricuspid annular dilation to receive mitral valve surgery alone or mitral valve surgery with concomitant tricuspid valve repair via tricuspid annuloplasty.
“Tricuspid regurgitation is common in patients undergoing mitral valve surgery for degenerative [mitral regurgitation],” James S. Gammie, MD, James T. Dresher, Sr. Professor in Cardiac Surgery and surgical director of the Johns Hopkins Heart and Vascular Institute and cardiac surgeon-in-chief for the Johns Hopkins Health System, said during an American Heart Association Scientific Sessions press conference. “There is broad agreement that when a patient has severe tricuspid regurgitation, then that valve should be repaired. However, there is significant uncertainty in how to manage moderate or less tricuspid regurgitation. There are some data from observational studies that failure to manage less than severe [tricuspid regurgitation] is associated with decreased survival and heart failure. There is wide practice variation among surgeons in deciding whether to repair this or not.”
At baseline, 37% of patients had moderate tricuspid regurgitation and 44% had atrial fibrillation. Cardiopulmonary bypass time was 34 minutes longer in the concomitant tricuspid repair group, Gammie said.
The primary endpoint of treatment failure, defined as death, reoperation for tricuspid regurgitation or progression of tricuspid regurgitation to severe or by two or more grades, at 2 years occurred in 10.2% of the control group compared with 3.9% by the tricuspid repair group (RR = 0.37; 95% CI, 0.16-0.86; P = .02). The difference was driven almost entirely by progression of tricuspid regurgitation, Gammie said. There were no reoperations for tricuspid regurgitation in either group.
Among patients with less than moderate tricuspid regurgitation at baseline, there was no difference between the tricuspid repair and control groups in the primary endpoint (control, 6.1%; tricuspid repair, 3.4%; RR = 0.56; 95% CI, 0.17-1.87), but among those with moderate tricuspid regurgitation, the primary endpoint was much more frequent in the control group (18.1% vs. 4.5%; RR = 0.25; 95% CI, 0.07-0.83), Gammie said.
At 2 years, the tricuspid repair group had lower rates of severe tricuspid regurgitation (5.6% vs. 0.6%; RR = 0.1; 95% CI, 0.01-0.77) and moderate or severe tricuspid regurgitation (25.1% vs. 3.4%; RR = 0.13; 95% CI, 0.06-0.3), according to the results.
Pacemaker implantation was more frequent in the tricuspid repair group (14.1% vs. 2.5%; RR = 5.75; 95% CI, 2.27-14.6) compared with the control group, Gammie said.
There was no difference between the groups at 2 years in all-cause mortality, major adverse cardiac and cerebrovascular events, readmissions, quality of life or functional status.
The results were simultaneously published in The New England Journal of Medicine.
“Tricuspid annuloplasty in patients with moderate or less tricuspid regurgitation decreased treatment failure, and this was driven by progression of [tricuspid regurgitation] in the moderate [tricuspid regurgitation] group,” Gammie said during the press conference. “This reduction came at the cost of an increased risk of permanent pacemaker implantation. Long-term follow-up is ongoing to determine the net clinical benefit.”
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Joanna Chikwe, MD, FRCS
The most important message is that if I have a relatively low-risk patient with a good life expectancy who has moderate tricuspid regurgitation, I am going to repair the mitral valve and the tricuspid valve at the time of surgery.
The inconsistency of clinical practice in this area partly reflects the lack of robust compelling data and also reflects the concern by cardiologists and surgeons that intervening on a valve that looks healthy and normal and functions in a healthy and normal fashion could contribute to worse outcomes for patients.
There is clearly an extreme of practice in the U.S. There are centers that repair the tricuspid valve as little as 5% of the time and centers that repair it more than 60% to 75% of the time. The sweet spot is clearly going to be somewhere in the middle. This trial gives us very good information on where the sweet spot is and which patients drove the endpoint.
The fact that incremental burden of pacemakers in this trial was so high was a very interesting finding. If you repair 20 of these valves, you save one progression of regurgitation for every two pacemakers. That is one thing that inhibits a more aggressive approach, particularly in younger patients. There are surgical techniques that can be employed to minimize the risk of a pacemaker. You can also wait longer after surgery, when somebody is in conduction block, before you decide to put a pacemaker in. The longer-term outcomes of the trial will hopefully give us a clearer idea of where the balance of this lies.
I suspect surgical thresholds for intervening on a tricuspid valve may lower ahead of research, because we now know there is a tricuspid transcatheter option potentially available for patients down the line.
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Gammie JS, et al. LBS.01. Valves, Veins and New Viewpoints in Cardiothoracic Surgery. Presented at: American Heart Association Scientific Sessions; Nov. 13-15, 2021 (virtual meeting).
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