Which patient undergoing mitral valve surgery should also have the tricuspid repair?

doi:10.1510/icvts.2009.217570 Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 www.icvts.org Best evidence topic - Valves Which patient undergoing mitral valve surgery should also have the tricuspid repair? Giacomo Bianchi*, Marco Solinas, Stefano Bevilacqua, Mattia Glauber Department of Adult Cardiac Surgery, Heart Hospital G. Monasterio Foundation, Massa, Italy Received 29 July 2009; received in revised form 20 August 2009; accepted 9 September 2009 Work in Editorial New Ideas Progress Report Protocol Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was Which patient undergoing mitral valve surgery should also have the tricuspid repair? Altogether 390 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. While a general agreement exists for tricuspid valve (TV) repair in cases of severe regurgitation and concomitant multivalvular disease requiring surgical intervention, current guidelines provide more vague indications for patients with less severe tricuspid regurgitation (TR). Since this condition has a lower event-free survival rate and the prognosis after symptoms development is dismal, a lower threshold and a more aggressive strategy for intervention is needed. In rheumatic valve disease, mitral valve involvement and disease spreading to TV may be responsible for further regurgitation. Although patients with pulmonary hypertension (PH) may benefit from mitral valve replacement (MVR) or balloon valvotomy, many studies found that preoperative PH does not predict late TR. However, patients with high pulmonary pressure have a lower occurrence of late TR. Tricuspid annular dilation is probably the most important factor for late TR. Once established, it might be irreversible even after resolution of PH as well as absence of reverse remodelling. It has been proposed to treat TR independently from the grade of regurgitation when 2 the annular dimension is over 21 mmym or G3.5 cm at echo measurement or when the intra-operative tricuspid annulus (TA) diameter is )70 mm. TV repair should be accomplished in patients with preoperative atrial fibrillation (AF), since it may cause late significant TR development and affect the patient s long-term survival. The presence of a trans-tricuspid pacemaker lead is another known factor for late TR development secondary to adhesions and fibrous retraction. TV repair is probably better than replacement in non-severe organic TV disease. Annuloplasty ring repair has better outcome compared with non-ring based repair techniques; the beneficial effect is also independent of the type of mitral valve surgery performed. 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Institutional Report ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper Keywords: Left-sided valve surgery; Tricuspid valve repair; Outcome 1. Introduction A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS w1x. 2. Three-part question In wpatients undergoing mitral valve surgery with moderate tricuspid regurgitationx is wtricuspid repairx superior to wmitral surgery alonex to prevent wlate tricuspid valve regurgitationx? 3. Clinical scenario A 65-year-old woman with severe mitral valve regurgitation and atrial fibrillation (AF) is scheduled for intervention; tricuspid annulus is 40 mm with mild tricuspid *Corresponding author. Mobile: q393404680379; q14438138914. E-mail address: gbianchi@ifc.cnr.it (G. Bianchi). 2009 Published by European Association for Cardio-Thoracic Surgery regurgitation (TR) and right ventricular (RV) dilation but no increase in pulmonary artery systolic pressure (PASP). Should tricuspid valve (TV) be repaired and what further operative risk and impacts will this have on your patient s early and late outcomes? 4. Search strategy Medline 1950 to August week 1 2009 using OVID interface: wtricuspid regurgitation.mp. OR exp Tricuspid Valve Insufficiencyyx AND wmitral regurgitation.mp. OR exp Mitral Valve Insufficiencyyx AND wmitral valve repair.mp. OR mitral valve replacement.mp. OR tricuspid valve repair.mp OR tricuspid valve replacement.mp. OR exp Thoracic Surgeryy OR valve surgery.mp. OR exp Heart Valve Prosthesisyx 5. Search outcome Three hundred and ninety papers were found using the reported search. From these, seventeen papers were identified that provided the best evidence to answer the question. These are presented in Table 1. State-of-the-art Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication

1010 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 Table 1 Best evidence papers Bonow et al., Class I Severe TR in the setting of ACCyAHA VHD surgery for multivalvular Guidelines: (2008), disease should be focused update corrected (level of evidence: c) Class II Tricuspid annuloplasty is reasonable for mild TR in patients undergoing MV surgery when there is pulmonary hypertension or tricuspid annular dilatation Vahanian et al., Class IIa Concomitant TV repair if (2007), Eur TA diameter )40 mm Heart J, ESC guidelines TV repair in patients with symptomatic, isolated TR late after left-sided valve surgery, in absence of left-sided myocardial or RV dysfunction and without severe pulmonary hypertension Turina et al., 170 patients Follow-up Mean 10.6 years (1802 Retrospective study (1999), (between 1975 patient-years) Circulation, and 1989) who Significant TV regurgitation requiring Switzerland, w2x underwent surgery Surgical procedures Double valve surgery 170 surgical repair worsened the prognosis for chronic patients Retrospective combined aortic Advice for TV repair when hemodynamic study (level IIb) and mitral valvular TV surgery 29 patients (17%) significant regurgitation is present disease CABG 7 patients (4%) Ascending aorta surgery 7 patients (4%) Reoperation involving Tricuspid replacement 2 TV patients Tricuspid reconstruction 2 patients Survival rate in patients with TR Predictors of late outcome At 10 years (cumulative survival) With TV reconstruction 57% Without TV reconstruction 68% Age (Ps0.0011) LVEF (Ps0.0008) Additional TV regurgitation (Ps0.007) Nath et al., 5223 patients One-year survival 91.7% with no TR, Retrospective study (2004), J Am Coll undergoing 90.3% with mild TR, Cardiol, USA, w3x echocardiography; 78.9% with moderate TR, Huge cohort of patients four years follow- 63.9% with severe TR Retrospective up; comparison Long follow-up study (level IIb) survival differences TR grade, pulmonary Moderate or greater TR among TR grades artery pressure and increased mortality regardless Unknown NYHA class at follow-up mortality of PASP HR 1.31 for PASP )40 mmhg; HR 1.32 PA No data correlation with MR grade and TR -40 mmhg TR grade, LVEF and mortality Moderate or greater TR increased mortality regardless of EF HR 1.49 EF-50% HR 1.54 EF)50%

G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 1011 Porter et al., 65 patients with Follow-up duration 11.3"8 years (range Retrospective study (1999), J Heart rheumatic heart 1 30 years) Valve Dis, disease who had No data about preoperative TR Israel, w4x undergone MVR Left-sided valve MV stenosis 44 patients (67%) without TV pathology and surgical MV regurgitation 21 patients No data on preoperative RV status Retrospective surgery intervention (33%) study case series Outlines the late development rate of TR (level IIIb) Mitral valve replacement in all when uncorrected at the time of left-sided cases valve surgery Outcomes 44 patients (67%) developed late TR Moderate 16 patients (36.4%) Severe 18 patients (41%) Risk factors Age RR 1.1 female gender 1.8 Matsuyama et al., Between March Mean follow-up 8.2"3.6 years (range 1.0 14.5 Retrospective study (2003), Ann Thor 1988 and years) Surg, Japan, w5x September 2001 of Long overall follow-up but high variability 174 of 274 patients Late deaths 14 late deaths (8%) of time (may underestimate late TR Retrospective undergoing MV development in some early patients) study (level IIb) surgery did not Early postoperative TR (3qy4q or more) in 4 receive concomitant outcome patients (2%) Mitral valve repair as left-side valve TV surgery surgery in 53% of patients Follow-up of TR grade 28 patients developed TR grade 3q or more (16%) 46 patients Progression of TR over time with preopearative TR 2qy4q, TR had progression in Early postoperative TR grade is unreliable 17 patients (37%) for estimation of late TR progression Risk factors for Preoperative 2q TR: OR 3.9 No assessment of right ventricular significant TR (3q (Ps0.004) AF: OR 9.2 (Ps0.03) dysfunction or tricuspid annulus dilatation or more) left atrium size: OR 2.8 (Ps0.03) Strong correlation with AF and atrial size Recommendation for aggressive TR repair in selected cases Matsunaga et al., From January Tricuspid annuloplasty 21 patients had preoperative Retrospective study (2005), Circulation, 1992 to December TR (moderate or greater) USA; Japan, w6x 2001, 124 9 patients underwent TVRep Relatively small number of patients consecutive (TR-group) 12 patients TR was Retrospective patients with fmr ignored (no-tr group) Long and complete follow-up study (level IIb) underwent CABG and MVRep. 21 TR moderate or greater 4 patients (44%) of TR group 50% of patients after MVRep showed patients (30%) had at follow-up 8 patients (67%) of no-tr group significant TR at follow-up TR before surgery (PsNS) Presence or absence of residual MR do not Progression of TR after Significant TR 25% at 1 year, affect the incidence of follow-up TR MVRep 53% at 1 3 years, 74% over 3 years Revascularization and MVRep do not reduce RV pressure overload and do not Follow-up MR and TR 14 of 21 patients (64%) with prevent late TR significant recurrent MR had also significant TR Incidence of late TR was independent of whether the TR was surgically treated or 20 of 48 patients (42%) with no ignored (44% vs. 67%; PsNS) recurrent MR had significant TR (PsNS) Significant recurrent MR (31%) reinforces the significance of ventricular geometric Follow-up echo data RV systolic pressure in the TR distortion as ongoing remodelling affecting group was higher than the no-tr RV and LV geometries group Best Evidence Topic LV ejection fraction was not different between the groups

1012 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 Calafiore et al., From January Follow-up duration 68 months (100% complete) Moderate-or-more ftr, if untreated, can (2009), Ann 1988 to March impair both midterm survival and functional Thorac Surg, 2003, 110 patients Mortality Treated vs. untreated TR group status, even if it seems not to affect early Italy, w7x with functional 30 days: 2% vs. 8.5% outcome mitral regurgitation (Ps0.213) long-term (46y104 Retrospective undergoing mitral patients) 16 patients vs. Reversal of TV remodeling cannot be study (level IIb) valve surgery 30 patients expected with MV surgery alone showed moderateor-more functional TR At 12 months follow-up Functional TR progression is not related to TR repaired with (77 patients) functional MVR progression De Vega technique Treated group (42 patients) Surgical technique can then influence the No TR: 50% late results of TR correction TR 1q: 31% TR 2q: 14% TR 3q: 5% Untreated group (35 patients) No TR: 0% TR 1q: 23% TR 2q: 37% TR 3q: 34% TR 4q: 6% MVR progression and influence on ftr recurrenceyprogression Survival MV repair (60 patients) MR 3q: )3 patients (5%) Late ftr group vs. non late ftr 2y47 (4.3%) vs. 1y13 (7.7%) Ps0.625 5 years treated vs. untreated TR 45.0"6.1% vs. 74.5"5.1% (Ps0.044) Risk factors of Lower mid-term survival (HR 2.7) untreated moderate-or-more TR Survival in NYHA class II or II (HR 1.9) Boyaci et al., Sixty-eight (68) TR grade, LVEF and Moderate or greater Retrospective study (2007), patients undergone mortality TR increased mortality Angiology, MVR without regardless of EF Improvement of functional capacity Turkey, w8x TV surgery HR 1.49 EF-50% in 86% of patients with mild HR 1.54 EF)50% preop TR vs. 54% of those with Retrospective significant TR study (level IIb) Preoperative TR Mild TR (group I) 42 patients (62%) Right ventricular pressure fell and remained lower in patients with mild TR, but not in Significant TR (group II) 26 patients with moderate to severe TR patients (38%) Transmitral F-U Group I vs. Group II (mmhg) gradient 5.2"2.5 vs. 5.6"3.0 (PsNS) Right ventricular Group I (mmhg) 47"1.0 to systolic pressure 31"10 trend prepostoperative Group II 45"9 to42"12 Pulmonary Group I vs. Group II (mmhg) hypertension at F-U 31"10 vs. 42"12 (P-0.05) NYHA Class at F-U Group I vs. Group II NYHA I 19% vs. 2% (P-0.05) NYHA II 67% vs. 46% (P-0.05)

G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 1013 NYHA III 14% vs. 38% (P-0.05) Hospitalizationyyear Group I vs. Group II 1.1"0.4 vs. 1.8"0.7 (P-0.05) Song et al., Between 1995 and Follow-up Clinical 101"24 months (range Retrospective study (2009), 2000, 638 patients 12 146 months) Heart, (356 men) with Extensive number of patients Korea, w9x mild (Fgrade 2y4) Echocardiographical TR underwent 64"30 months (range 14 141 Outlines the natural history of late TR Retrospective surgery without months) development study any procedure on (level IIb) the TV Left-side valve surgery Mitral valve surgery Rheumatic aetiology is strongly associated 323 patients with development of late significant TR Aortic valve surgery 221 patients Female gender has higher incidence probably due to higher prevalence of Double-valve surgery rheumatic disease in this population 94 patients AF is the most striking risk factor for Significant late TR Mitral valve surgery 9.6% development of late significant TR development (31y323 patients) PH is not associated with TR progression Aortic valve surgery 3.2% (7y221 patients) Right ventricular distortion or annular dilatation is associated with late TR Double-valve surgery 11.7% development (11y94 patients) Impact of rheumatic Rheumatic MR 15% (10y65 disease on late TR patients) Non-rheumatic MR 5% (7y133 patients) (Ps0.017) AF 239 patients (37%) before surgery 184 patients persistent AF TV annular dilatation Late TR risk factors Mortality Event-free survival 18 patients (5%) developed AF at follow-up TV annulus increased in both group Late TR 32"6 to40"7 mm Non late TR 40"7 mm P-0.001 Age (HR 1.0; Ps0.005) Female gender (HR 5.0; Ps0.001) rheumatic aetiology (HR 3.8; Ps0.011) AF (HR 2.6; Ps0.035) peak pressure gradient of TR (HR 1.1; -0.001) Significant TR vs. non late TR 4.9% vs. 16.3% (Ps0.004) Late TR vs. non-late TR 76"6% vs. 91"1% (P-0.001) Best Evidence Topic

1014 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 Colombo et al., From January Follow-up 25"15.9 months (range 3 49 Prospective study (2001), Cardiovasc 1995 to December months) Surg, Italy, w10x 1998, 50 patients Absence or mild to moderate TR in 83.9% with rheumatic Surgical procedure MVR with mechanical valve: of patients who underwent tricuspid Prospective mitral valve 47 patients procedure single center disease and cohort study functional MVR with bioprosthesis: Undersizing of TV annulus has been (level IIb) TR underwent 3 patients effective even with the De Vega procedure surgery for TVRep with De Vega procedure: MVR and TV 33 patients repair Outcome TVRep group with 3q or 4q TV repair TR Grade 0 or 1q: 19 patients performed if (73%) Grade 1q or 2q: indexed TV 3 patients (11.5%) Grade 2q annular dimension or 3q: 1pt(3.8%) Grade 3q to )21 mmym 2 4q: 3 patients (11.5%) Two patients of five with TV 2 annulus )21 mmym who did not undergo TV annuloplasty had significant TR at follow-up Dreyfus et al., Between 1989 and Mortality No significant difference Retrospective study; consecutive patients (2005), Ann 2001, 311 patients (group 1s1.8%; group 2s0.7%) Thorac Surg, underwent mitral 10 years follow-up patients UK, w11x valve repair Actuarial survival rate Group 1s97.3%, 96.2%, and (MVR). Tricuspid 85.5%; group 2s98.5%, Precise and reproducible method of TV Retrospective annuloplasty 98.5%, and 90.3% at 3, 5, and sizing is used study (level IIb) performed if 10 years, respectively tricuspid annular Demonstrates little or no correlation diameter G70 mm NYHA class Improved in group MVRqTV between tricuspid dilatation and regardless of the annuloplasty (group regurgitation grade of 1s1.59"0.84; group regurgitation. 2s1.11"0.31; Tricuspid dilatation is more reliable than Group 1 MVR P-0.001) TR when assessing secondary TV disease alone (163 patients; 54.4%); TR grade Increased )2 grades in Group 2 MVR 48% of group 1 (MVR alone) plus tricuspid and only 2% in group 2 (MVRq annuloplasty (148 TV annuloplasty) patients; 47.6%) McCarthy et al., From 1990 to Follow-up 8 years (3302 patient-years) Retrospective study no consistent, (2004), J Thorac 1999, 790 patients accurate data for right ventricular function, Cardiovasc Surg, underwent Left-sided valve MVR 425 patients (54%) size and geometry, TV annular size, PAPs USA, w12x TV annuloplasty surgery and other for functional procedures MVRep 276 patients (35%) No analysis of residual MR Cohort study regurgitation using (level IIb) 4 techniques: AVR 199 patients (25%) No analytical correlation between TR and 1. Carpentier survival or progression of NYHA class Edwards semi-rigid AVRep 15 patients (2%) ring Residual TR in 14% of patients early after 2. Cosgrove CABG 205 patients (265) operation Edwards flexible band Distribution of patients Carpentier: 139 patients Late worsening (beyond 6 months) 3. De Vega according to TV repair (17%) associated with patient disease factors procedure technique AND with avoidable causes such as trans- 4. Peri-Guard Cosgrove: 291 patients (37%) tricuspid pacing leads and type of annuloplasty annuloplasty De Vega: 116 patients (15%) 2 non-ring annuloplasties, De Vega and Peri-Guard: 243 patients (31%) Peri-Guard, worsening of TR. Reoperation rate Freedom from reoperation 1 month: 99% 8 years: 97%

G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 1015 Progression to grade Carpentier 3q: 10% - 10% - 3q or 4q TR according 11% - 11% 4q: 5.2% - 5.5% - to TV repair technique 6% - 6% (Ps0.7) 1 month Cosgrove 3q: 10% - 12% - 1 year 12% - NA 4q: 5.3% - 6% - 6% - NA 5 years (Ps0.05) 8 years De Vega 3q: 9% - 12% - 17% - 20% 4q: 4.6-6% - 11% - 13% (Ps0.002) Peri-Guard 3q: 10% - 13% - 19% - 22% 4q: 5.4% - 7% - 13% - 15% (Ps0.0009) Pacemaker lead influence on 3q and 4q TR prevalence Preop TR influence of late TR development (Prevalence of 3q or 4q) 1. grades 0 vs. 1q 2. 2q vs. 3q 3. vs. 4q Risk factors for late TR worsening Preop PMK Lead vs. No PMK Lead 16% - 42% vs. 15% - 23% (1 month 5 years) 9% - 14% - 22% at 1 month 18% - 23% - 29% at 5 years LV dysfunction (Ps0.0002) One-system disease (Ps0.007) AF (Ps0.01) PMK lead (Ps0.04) Tang et al., Between 1978 and Follow-up duration 5.9"4.9 years (range Majority of patients undergoing TV repair (2006), Circulation, 2003, 702 patients 0 21 years) have secondary ( functional ) regurgitation Canada, w13x underwent TV repair in the setting TR repair De Vega procedure 493 Uncorrected moderate and severe TR may Retrospective of concomitant patients persist or even worsen after mitral valve study (level IIb) left-sided valve surgery surgery and Ring annuloplasty 209 patients: revascularization Carpentier n. 114 (54%) Annuloplasty ring refers significant Duran n. 52 (25%) improvement over De Vega repair in long- Cosgrove n. 43 (21%) term survival and event-free survival, as well as recurrence of TR Functional class Ring vs. non ring TV repair NYHA III IV 20% vs. 25% Beneficial effects of a TV annuloplasty ring were independent of the type of Late TR Ring group No TR 15% mitral valve surgery performed Trivial-to-mild TR 55% Moderate-to-severe TR 30% Non-ring group No TR 10% Trivial-to-mild TR 54% Moderate-to-severe TR 36% Recurrence of TR was not significantly associated with the recurrence of MR Best Evidence Topic Outcomes No ring vs. ring (15 years) Freedom from TR 39"11% vs. 82"5% (Ps0.003) Long-term survival 36"8% vs. 49"5% (Ps0.007) Event-free survival 17"6% vs. 34"5%

1016 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 Predictors Annuloplasty ring Long-term survival (HR 0.7; Ps0.03) Event-free survival (HR 0.8; Ps0.04) Kim et al., From January Distribution of patients Carpentier: 139 patients (17%) Retrospective study (2005), 1994 to December according to TV repair Circulation, 1997, 170 patients technique Cosgrove: 291 patients (37%) Long follow-up Korea, w14x underwent leftside valve surgery De Vega: 116 patients (15%) Tricuspid repair techniques used are also Retrospective and MAZE (Cox known to be burden by high late TR study III) operation for Peri-Guard: 243 patients (31%) recurrence (level IIb) AF Group I 44 patients in sinus Reoperation rate Freedom from reoperation AF affects the worsening of TR over time rhythm; Group II 1 month: 99% 48 patients in AF 8 years: 97% MAZE can prevent this course with MAZE and Group III 78 Preoperative TR grade Group I 12 patients (27.3%) Recovery and maintenance of atrial patients without Group II 8 patients (16.7%) mechanical activity are of great value for MAZE Group III 26 patients (33.3%) such a benefit Progression of TR at follow-up Immediate results (significant TR) Group I 3 patients (6.8%) Group II 1 pt (2.1%) Group III 11 patients (14.1%) PsNS among groups Post-op results (significant TR) Group I 3y41 patients (7.3%) Group II 6y47 pt (12.8%) Group III 26y67 patients (38.8%) Ps0.001 Group I vs. Group III Ps0.005 Group II vs. Group III Atrial contractility contribution and analysis Group II (qmaze) 38 patients of Group II maintained sinus rhythm (Group IIa) 10 patients with no LA mechanical activity (AF, accelerated junctional rhythm, sinus rhythm) Group IIa had smaller LA size preoperatively and lower TR grade at the final follow-up than those in Group IIb (Ps0.038; Ps0.025) Left-side valve surgery MVRyMVRep 174 patients (51.9%) AV surgery alone 74 patients (22.1%) Combined MVqAV surgery 87 patients (4.5%) MVRyMVRep 174 patients (51.9%) AV surgery alone 74 patients (22.1%) Combined MVqAV surgery 87 patients (4.5%)

G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 1017 TV surgery and Annuloplasty 15 patients (4.5%) technique TR development Significant: 90 patients (26.9%) Severe in 25 patients (7.5%) TR population and risk Age (47.6"13.4 vs. 44.3"13.2 factors (TRq vs. TR-) years, Ps0.04) Event-free survival TR- group at 100, 140, 160 and 97.0"1.1% 175 months 87.7"2.8% 85.9"2.6% 85.9"2.6% Preop AF (83.3 vs. 46.5%, P-0.001) LA dimension (56.9"13.2 vs. 52.4 "11.5 mm, Ps0.006) Prior valve surgery (40.0 vs. 25.3%, Ps0.01). TRq group 94.4"2.4% 86.2"3.7% 70.9"5.9% 62.0"9.8% Ps0.03 Jonjev et al., From July 1994 Follow-up duration Mean 42 months (range In end-stage heart disease and selected (2007), J Card to July 2004, 1 120 months) patient population the RADO procedure is Surg, Serbia and 226 of 294 effective Montenegro, w16x patients who Functional status Preopertative NYHA class III underwent surgical 70 patients (39.88%) Concomitant reduction of mitral and Prospective intervention for NYHA class IV 126 patients tricuspid insufficiency provides early and study (level IIb) chronic ischemic (69.02%) mean NYHA class long-term beneficial effect, according with mitral 3.9 the natural history of the disease regurgitation had reductive Surgical procedure Mitral valve surgery No data are provided about the long-term annuloplasty of efficacy of De Vega annuloplasty for the double orifices Carpentier mitral ring prevention of late TR development (RADO) 37 patients (16.38%) Semicircular posterior annuloplasty 189 patients (69.02%) TV surgery Best Evidence Topic De Vega annuloplasty 226 patients (100%) Follow-up RADO results Mean NYHA class 1.9 mean EF preoperative 25% to postoperative 34% Mitral valve insufficiency mean grade 3.7"0.4 preoperative to 0.7"0.3 postoperative TV insufficiency mean grade 3.4"0.4 preoperative to 0.9"0.2 prostoperative Survival 5 years 10 years 61.5"4.0% 38.05"8.0%

1018 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 Freedom from At 10 years 60.0"6.7% decompensation De Bonis et al., Ninety-one DCM Follow-up 1.8"1.2 years (range 0.5 5.7 Retrospective study (2008), Eur J patients (mean age years) Cardiothorac Surg, 61"11.3) No consistent, accurate data were available Italy, w17x submitted to MV Left-sided surgery Edge-to-edgequndersized preoperatively and at follow-up regarding repair ("tricuspid and concomitant annuloplasty 46 patients right atrial dimension, tricuspid annular size Cohort study repair) for procedures (50.5%) undersized and degree of leaflet tethering (level IIb) functional MR annuloplasty 45 patients (49.4%) Small number of patients included CABG 41 patients (45%) uncorrected moderate or less TR in patients AF surgery 14 patients (15.3%) with functional MR often persist and worsen over time TV surgical 13 patients (3qy4q or intervention )TR ) had TV annuloplasty: Annular dilatation and tethering as underlying mechanisms of late TR De Vega Procedure: 7 patients Ring annuloplasty: RV function assessment is essential to 6 patients guide the surgical intervention No TV annuloplasty: 78 patients (with TR-2qy4q) Absence of reverse remodelling influences late TR development Evolution of ftr Absentymild 52 patients (57.1%) Moderate 28 patients (30.7%) Moderately severe 9 patients (9.8%) Severe 2 patients (2.2%) 11 of 91 patients (12%) had progression of TR 14 of the 78 patients (17.9%) no-tr had worsening of TR at least of 2 grades TR evolution mechanisms Predictors of significant late TR Annular dilatation in 75 patients tethering in 6 patients RV dilatation (OR 8.3, Ps0.009) Pre-op. RV dysfunction (OR 13.7, Ps0.0001) TR grade at discharge (OR 5.4, Ps0.01) Pulmonary hypertension Significant ()3q) TR at follow-up: 37% (9y24) among the patients with pulmonary hypertension 3% (2y67) among those with SPAP -40 mmhg at the last echocardiogram (P-0.0001) Pattern of LV reverse remodeling group: remodeling Significant TR in only 1 of 49 patients (2%) that demonstrated reverse remodeling

G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 1019 No reverse remodeling group significant TR in 10 of 42 patients (23.8%) (Ps0.04) fmr, functional mitral regurgitation; MVRep, mitral valve repair; FTR, functional tricuspid regurgitation; TVRep, tricuspid valve repair; PMK, pacemaker; TTE, trans-thoracic echocardiography; TA, tricuspid annulus; MR, mitral regurgitation; AVR, aortic valve replacement; AVRep, aortic valve repair; AV, aortic valve; HR, hazard ratio; OR, odds ratio. 6. Results In 1999, Turina et al. w2x reported that significant tricuspid regurgitation (TR) requiring TV surgery predicts poor survival in patients undergoing valve surgery. Nath et al. w3x found that the survival rate at one year changes significantly in moderate and severe TR groups. Moderate and severe TR increases the mortality regardless of PASP degree and ejection fraction. Porter et al. w4x outlined that among patients who underwent mitral valve replacement (MVR) without TV surgery, 44 (67%) developed late TR (moderate to severe in 34 patients, 77.4%). Matsuyama et al. w5x analyzed the outcome of 174 patients that did not receive TV surgery at the time of intervention. Despite a low percentage in the early postoperative period, 28 patients (16%) developed a TR grade of 3q or more and, out of those with preoperative TR 2qy4q, a progression was observed in 17 patients (37%). Early postoperative TR grade is unreliable for estimation of TR progression. In their series of 124 patients with functional mitral regurgitation (fmr) who underwent CABG and mitral valve repair (MVRep), Matsunaga et al. w6x found no difference in early postoperative TR among corrected-tr and uncorrected-tr groups, but at the last follow-up, 34 patients (49%) had significant TR. The incidence of TR increased from 25% at -1 year to 53% between 1 and 3 years and 74% at )3 years. In the analysis of Calafiore et al. w7x, ftr progression is not related to MVR progression and untreated moderate or more functional TR can impair both mid-term survival and functional status, as outlined by the study of Boyaci et al. w8x. Recently, Song et al. w9x found that TV annulus size tends to increase over time in either corrected or uncorrected TR. Rheumatic aetiology of mitral valve (MV) disease is also associated with development of significant late TR (15% vs. 5%, Ps0.017). In the series of Colombo et al. w10x, 50 patients undergoing mitral valve surgery had their TV corrected if the indexed 2 tricuspid annulus dimension was G21 mmym. At followup, 83.9% of patients who underwent tricuspid procedure had absent or mild and mild-to-moderate TR. In 2005, Dreyfus et al. w11x reported a series of 148 patients where an intra-operative TV annular diameter wtricuspid annulus (TA)x G70 mm was used as criterion for repair, regardless of the preoperative TR grade (equivalent to 4 cm by echocardiography wa. Berrebi, personal communication, November 2006x). TR increased more than two grades in 48% of patients in the no-tv repair group and only in 2% of the MVRqTVRep group. No correlation has been found between preoperative TA dilatation and regurgitation grade. In 2004, McCarthy et al. w12x analyzed 790 patients who had TV repair using two ring (Carpentier Edwards, Edwards flexible band) or two non-ring techniques (De Vega Peri-Guard). Freedom from re-operation was 97% at follow-up. TR severity was stable across time with Carpentier Edwards ring (Ps0.7), increased slowly with Cosgrove Edwards band (Ps0.05), but rose more rapidly with the De Vega (Ps0.002) and Peri-Guard (Ps0.0009) approach. The non-ring annuloplasties showed to be ineffective in preventing late TR development. Presence of pacemaker (PMK) leads were also identified as a risk factor (42% at 5 years). Significant improvement with ring annuloplasty over the De Vega technique in terms of long-term survival, eventfree survival and recurrence of TR has been confirmed by Tang et al. w13x; furthermore, the beneficial effects are independent of the type of the MV surgery performed. Kim et al. w14x outlined that when AF persists after surgery for left-sided valve or when the left atrium mechanical activity is not restored, progression to high grade TR occurs. A recent paper from Kwak et al. w15x reported that 90 patients (26.9%) of 335 with no preoperative TR, undergoing left-sided valve surgery, developed de novo significant TR. Preoperative AF was found to independently contribute to late TR. In the setting of end-stage heart disease, the group of Jonjev et al. w16x outlined that reductive annuloplasty of mitral and TV is an effective procedure with early and long-term beneficial effects on survival, freedom from hospitalization and improvement of functional class. Of 91 patients with dilatative cardiomyopathy submitted to MV repair, De Bonis et al. w17x found that, among those who did not have TR repair, TR worsening of at least 2 grades occurred. Right ventricle dilatation, preoperative RV dysfunction and TR grade at discharge were strong predictors of late significant TR development. Pulmonary hypertension (PH) was also associated with significant TR (grade 3qor more) at follow-up. The absence of reverse remodelling occurred in a significant percentage of patients with late TR (10 patients; 23.8% Ps0.04). Best Evidence Topic

1020 G. Bianchi et al. / Interactive CardioVascular and Thoracic Surgery 9 (2009) 1009 1020 7. Clinical bottom line TV insufficiency should be treated during left-sided valve 2 surgery when TR annulus is dilated (G21 mmym ;)70 mm intra-operatively; G3.5 cm at trans-thoracic echocardiography (TTE) w18x) regardless of the absolute grade of regurgitation, in cases of preoperative AF, trans-tricuspid PMK lead and underlying rheumatic disease. Also, ring annuloplasty techniques should be preferred over the nonring techniques. References w1x Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;4:405 409. w2x Turina J, Stark T, Seifert B, Turina M. Predictors of the long-term outcome after combined aortic and mitral valve surgery. Circulation 1999;100(19 Suppl):II48 II53. w3x Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004;3:405 409. w4x Porter A, Shapira Y, Wurzel M, Sulkes J, Vaturi M, Adler Y, Sahar G, Sagie A. Tricuspid regurgitation late after mitral valve replacement: clinical and echocardiographic evaluation. J Heart Valve Dis 1999;1:57 62. w5x Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery. Ann Thorac Surg 2003;6:1826 1828. w6x Matsunaga A, Duran CMG. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation 2005; 112(9 Suppl):I453 I457. w7x Calafiore AM, Gallina S, Iacò AL, Contini M, Bivona A, Gagliardi M, Bosco P, Di Mauro M. Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? a propensity score analysis. Ann Thorac Surg 2009;3:698 703. w8x Boyaci A, Gokce V, Topaloglu S, Korkmaz S, Goksel S. Outcome of significant functional tricuspid regurgitation late after mitral valve replacement for predominant rheumatic mitral stenosis. Angiology 2007;3:336 342. w9x Song H, Kim MJ, Chung CH, Choo SJ, Song MG, Song JM, Kang DH, Lee JW, Song JK. Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery. Heart 2009;11:931 936. w10x Colombo T, Russo C, Ciliberto GR, Lanfranconi M, Bruschi G, Agati S, Vitali E. Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc Surg 2001;4:369 377. w11x Dreyfus GD, Corbi PJ, Chan KMJ, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;1:127 132. w12x McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, Blackstone EH. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg 2004;3:674 685. w13x Tang GHL, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation 2006;114(1 Suppl):I577 I581. w14x Kim HK, Kim YJ, Kim KI, Jo SH, Kim KB, Ahn H, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS. Impact of the Maze operation combined with left-sided valve surgery on the change in tricuspid regurgitation over time. Circulation 2005;112(9 Suppl):I14 I19. w15x Kwak JJ, Kim YJ, Kim MK, Kim HK, Park JS, Kim KH, Kim KB, Ahn H, Sohn DW, Oh BH, Park YB. Development of tricuspid regurgitation late after left-sided valve surgery: a single-center experience with longterm echocardiographic examinations. Am Heart J 2008;115:732 737. w16x Jonjev ZS, Mijatov M, Fabri M, Popović S, Radovanović ND. Systematic reductive annuloplasty of the mitral and tricuspid valves in patients with end-stage ischemic dilated cardiomyopathy. J Card Surg 2007 Apr; 2:111 116. w17x De Bonis M, Lapenna E, Sorrentino F, La Canna G, Grimaldi A, Maisano F, Torracca L, Alfieri O. Evolution of tricuspid regurgitation after mitral valve repair for functional mitral regurgitation in dilated cardiomyopathy. Eur J Cardiothorac Surg 2008;4:600 606. w18x Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol 2009;5:401 408. ecomment: Which functional tricuspid regurgitation should be surgically corrected? Authors: Leo A. Bockeria, Bakulev Center for Cardiovascular Surgery, 121552 Moscow, Russia; Ivan I. Skopin, Irma M. Tsiskaridze doi: 10.1510/icvts.2009.217570A We thank Giacomo Bianchi and associates for their actual report w1x. Tricuspid regurgitation (TR) is common in patients with left-sided heart valve disease. It is well known that moderate or more functional TR should be repaired. Many investigators have recommended surgical treatment from moderate to severe TR and assumed that a mild degree of functional TR could be expected to diminish after surgical relief of left-sided valve pathology. But, correction of left-sided valvular disease does not automatically correct TR. Treatment of the mitral lesion alone only decreases the afterload. Neither does it correct tricuspid dilatation nor does it affect preload or right ventricular (RV) function w2x. Dilatation of the tricuspid annulus is progressive and may not be accompanied by TR initially, but eventually leads to it. The normal tricuspid valve (TV) annulus is saddle-shaped. It is known that with functional TR the annulus becomes larger, more planar, and circular. The flattening of the TV annulus that occurs with TR can potentially alter the normal papillary muscle-to-leaflet and annulus relationship. With flattening of the annulus, the low points of the annulus may be stretched away from the papillary muscles, thereby increasing tethering. The tricuspid annulus is a component of both the TV and the right ventricle w2x. Ton-Nu et al. w3x suggest that it is not the RV pressure load or left-sided heart disease that influences the annular remodeling changes observed with functional TR. It is the RV dysfunction and dilation that affect those annular remodeling changes. As suggested by Ton-Nu et al. w3x the RV dysfunction and TR are indeed linked, perhaps through the mechanism of annular shape. Possibly, the tricuspid annulus can be thought of as the gear that modulates the effects of the RV remodeling on TV function. Dreyfus et al. w2x demonstrated that the decision to perform tricuspid annuloplasty based on tricuspid annular dilation rather than on the degree of TR at the time of surgery resulted in improved long-term outcome. In our opinion, as the tricuspid annular dilatation seems to be the underlying mechanism regarding non-organic TR, it may be a more reliable indicator for TV pathology compared with TR w2x. We agree with the authors of this report w1x that TV insufficiency should be treated during left-sided valve surgery when the tricuspid annulus is dilated, regardless of the absolute grade of regurgitation. References w1x Bianchi G, Solinas M, Bevilacqua S, Glauber M. Which patient undergoing mitral valve surgery should also have the tricuspid repair? Interact CardioVasc Thorac Surg 2009;9:1009 1020. w2x Dreyfus GD, Corbi PJ, Chan KMJ, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg 2005;79:127 132. w3x Ton-Nu TT, Levine RA, Handschumacher MD, Dorer DJ, Yosefy C, Fan D, Hua L, Jiang L, Hung J. Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography. Circulation 2006;114:143 149.