Intraoperatively Quantitative Indication For Surgical Management Of Secondary Tricuspid Regurgitation

Part1Investigation of an alternative method based ontricuspid annular circumference index for thedecision-making of concomitant tricuspid valve plastyObjective: In the patients with less than moderate tricuspid regurgitation, tricuspidannular dilatation has been recommended as an independent indication forconcomitant prophylactic tricuspid annuloplasty. However, definition of dilatedtricuspid annulus is still difficult, and till now, there is no ideal standard. The purposeof the study was to introduce an intraoperatively quantitative method based on thetricuspid annular circumference to judge the extent of annular dilatation, andinvestigate its predictive ability for the late postoperative progression of tricuspidregurgitation(TR).Methods: From2010October to2011October, this study included patients withisolated mitral valve disease or mitral and aortic valve diseases undergoing mitralvalve replacement or double valve replacement in Beijing Anzhen Hospital. Thepatients with less than3+TR and echocardiographic ‘normal' tricuspid annulardiameter were finally enrolled. All the patients were undergone isolated left-sidedvalve surgery, and were assessed the tricuspid annular circumference intraoperatively. The postoperative follow-up was done by echocardiography. The end-point wasdefined as the progression of TR by more than two grades or final TR grade?3+onfollow-up echocardiographic examinations.Results: During one-year period,127patients were finally enrolled in this study.There were49male and78female, with average age53.3±10.9years old. More thanhalf patients accompanied atrial fibrillation, and the majority of etiology wasrheumatic left-valve lesions. The perioperative mortality was0.8%. The averagefollow-up time was30.2±11.8months, and the end-point event was met in23(18.7%)patients. Three variables were found to be associated with postoperative TRprogression, including atrial fibrillation, left atrium diameter and the intraoperativemeasured TACI with a p value about0.1in univariate analysis. But only the TACI(OR,1.586;95%CI1.303to1.929; p<0.001) was significantly associated withpostoperative TR progression in multiple regression analysis. Based on thereceiver-operator characteristic curve, an optimal cut-off value(83mm/m2) wasderived to predict postoperative TR development with higher sensitivity andspecificity.Conclusion: Tricuspid annular circumference assessed by our special sizers is anideal method for the surgeon to judge if the tricuspid annulus dilates or not duringsurgery and a deduced threshold of83mm/m2is recommended to perform theprophylactic tricuspid annuloplasty in order to refrain from postoperative TRprogression. Part2Verification of an intraoperative method basedon tricuspid annular circumference index for thedecision-making of concomitant tricuspid valve plastyObjective: Intraoperative measurement of the tricuspid annular circumference bytricuspid sizers is a relatively ideal method for assessing the extent of tricuspidannular dilatation according to our previous study. The purpose of this study is tofurther verify the feasibility and reliability of this alternative method for refrainingpostoperative progression of tricuspid regurgitation through a randomized controlledtrial.Methods: From2012October to2013November, this study included patients withisolated mitral valve disease or mitral and aortic valve diseases undergoing mitralvalve replacement or double valve replacement in Beijing Anzhen Hospital. Thepatients with2+TR and echocardiographic ‘normal' tricuspid annular diameter werefinally enrolled, and randomized to receive concomitant tricuspid valve plasty(TVPgroup) or receive isolated left-sided valve surgery(non-tricuspid valve plasty, NTVPgroup). All the patients were measured the tricuspid annular circumferenceintraoperatively. The preoperative, discharge and postoperative follow-up TR wereassessed by echocardiography. TR degrees at the time of preoperative, discharge andfollow-up period were compared between the TVP and NTVP group. For furtherinvestigation, all the patients with or without TVP were separately divided into twosub-groups based on the intraoperatively measured TACI lower or higher than thecut-off value83mm/m2. All statistical analyses will be performed using SPSS20.0software. Results:170patients were finally enrolled in this study, and randomized toreceive(n=86) or not receive(n=84) concomitant prophylactic tricuspid valve plasty.Patients in all sub-groups divided by intraoperatively measured TACI demonstratedno significant difference with regard to age, sex, atrial fibrillation, etiology ofleft-valve lesions and so on. There was no perioperative mortality. Two patients inTVP group and one in NTVP group were lost in follow-up. The average postoperativefollow-up time was20.2±10.2months. In TVP group, patients showed significant lessTR grade at discharge than preoperative grade, and sustained out in short-termfollow-up. In the NTVP group, TR grade diminished significantly at discharge,however, in the follow-up period, there was obvious TR progression, and4patientsreached significant tricuspid regurgitation(3+/4+). According to the intraoperativeTACI value, two sub-groups were divided in the NTVP group. Patients with the TACIless than83mm/m2did not show TR progression in follow-up, however, patients whohad more than83mm/m2TACI demonstrated significant development of TR grade.Selected all patients with TACI more than83mm/m2,38patients underwent TVP and40received isolated left-sided surgery, TR grade was significantly lower in the TVPgroup at both discharge and follow-up period.Conclusion: Intraoperative measurement of the tricuspid annular circumference byour customized sizers was a simple, feasible and reproducible method. We stronglyrecommended2+STR patients with TACI?83mm/m2should receive concomitantprophylactic tricuspid valve plasty, along with left-sided valve correction.