Clinical Study On Surgery For FunctionaI Tricuspid Valve Regurgitation Associated With Rheumatic Mitral Valve Disease

ObjectiveAlthough the incidence of rheumatic heart disease (RHD) in China has significantly decreased in the last years, yet it still possesses a prevalence of0.22‰as one of the most common chronic heart diseases and one of the heart diseases which could severely jeopardize human health and influence patients’ life quality. More than40%of the RHD patients suffer from mitral diseases, and persistent mitral stenosis or insufficiency often results in functional tricuspid regurgitation (FTR) secondary to valvular disorder in the left heart. Mitral diseases could result in pulmonary hypertension and increase of right ventricular volume overload,whose long-term presence could in turn leads to expansion of the tricuspid valve annulus and FTR, thus a vicious cycle is formed, resulting in complications including aggravated cardiac dysfunction, increased right atrial pressure, systemic congestion, edema in all limbs and hepatosplenomegaly with ascites, and consequently patients’ activity is limited and patients’ quality of life is largely influenced. Thus, most patients with moderate to severe functional TR need tricuspid valvuloplasty when receiving the mitral valve replacement. Many reports showed that mitral valve replacement (MVR) alone could cause both short-and long-term unpleasant influence on patients without correcting TR. Surgical treatment on TR secondary to mitral valve diseases remains an important challenge for cardiac surgeons. This study is a retrospective study, which assesses the short-and long-term outcomes of different annuloplasty by analyzing on116hospitalized patients with tricuspid insufficiency secondary to mitral valve diseases, in order to determine relatively appropriate surgical treatment strategies for variety of degrees of TR. Materials and MethodsIn this study, retrospective analysis is carried out among116patients, who were admitted by the Second Hospital of Shandong University during May2004to June2010and experienced TR secondary to rheumatic mitral valve disease, and all the subjects had received mitral valve replacement in the cardiac surgery of our hospital, and88of them received tricuspid annuloplasty at the same time. The study included47males and69females, and the average age is47.2±17.6years old. Preoperative cardiac function NYHA grading demonstrated that55(47.4%) subjects were Ⅰ-Ⅱ grade,49(42.2%) grade Ⅲ,12(10.3%) grade Ⅳ. Average pulmonary artery systolic pressure at admission was67.8±18.1mmHg, and it became (51.2±17.4) mmHg after treatment for lowing the pulmonary pressure. The patients were divided into3groups and8sub-groups according to their TR status under preoperative cardiac color ultrasonography:mild TR,36subjects (31.0%, Group Ⅰ), among which28(24.1%, group ⅠA) received palliative therapy (ie, non-TVP) and8(6.9%, group IB) received De Vega annuloplasty; moderate TR,45subjects (38.8%, Group Ⅱ), among which29(25.0%, group ⅡA) received De Vega annuloplasty,9(7.8%, group ⅡB) received Kay’s annuloplasty, and7(6.0%, group IIC) received Carpentier ring annuloplasty; severe TR,35subjects (30.2%, group Ⅲ), among which9(7.8%, group ⅢA) received De Vega annuloplasty,11(9.5%, group ⅢB) received Kay’s annuloplasty,15(12.9%, group ⅢC) received Carpentier ring annuloplasty. There is no significant difference among patients at the same TR grade before and after the surgery. The average follow-up duration is more than18months.ResultsThere were3deaths during the postoperative hospital stay,and the in-hospital mortality rate was2.6%. One week after the surgery, reexamination by cardiac color ultrasonography demonstrated that:for the mild TR group (Group Ⅰ),8(7.1%) experienced mild regurgitation one week after the surgery and were all in group IA; for the moderate TR group (Group Ⅱ),2(1.7%) had mild regurgitation one week after the surgery and Group ⅡA and ⅡB each had1(0.9%) of them; for the severe TR group, mild regurgitation happened in3(2.6%), including1(0.9%) in group ⅢA and2in group ⅢB, group2(1.7%), and there were no subjects with moderate or severe TR. There was no death during the follow-up period after discharge, and the postoperative survival rate was97.4%. For the113patients followed up for18months or more, ultrasonography18months after surgery suggested:13patients had mild TR (11.5%), among which,3was in group ⅠA,2in ⅡA,2in ⅡB,2in ⅢA,3in ⅢB and1in ⅢC;6had moderate TR (5.3%), and1in ⅠA,1in ⅡA,1in ⅡB,1in ⅢA,1in ⅢB,1in ⅢC;1(0.9%) had severe TR and was in group IIIB before the surgery. Cardiac color ultrasonography during follow-up showed that the size of the right atrium and right ventricle were reduced compared with that before the surgery for all the patients (P<0.01). Comparison of the efficacy of different surgeries among the sub-groups at the same TR degree:in group Ⅰ, there is no difference for the immediate efficacy, but group ⅠB is superior to group IA regarding long-term efficacy (P<0.05); for group II, the long-term effect of Group ⅡA is similar to that of group ⅡC (P>0.05) and superior to group IIB (P<0.05); the long-term efficacy in Group Ⅲ in descending order is as following:ⅢC, ⅢA, ⅢB (P<0.05).ConclusionDue to the complexity of its pathophysiological mechanisms and the anatomic specialness of tricuspid valve, functional tricuspid regurgitation secondary to rheumatic mitral valve disease is still one of the challenges to present cardiac surgeons. Appropriate surgical strategy is essential to the treatment of functional tricuspid regurgitation, since the right surgery could effectively prevent the pathophysiological progress of tricuspid regurgitation and even reduce the degree of regurgitation. In routine clinical practice, we should confirm the preoperative diagnosis and surgical indications for such patients, carry out appropriate TVPs for some of the mild TR patients and all the moderate and severe TR patients to eliminate or release the TR, and with careful perioperative treatment and care after discharge, increase the survival rate, reduce TR recurrence, improve the quality of life and extend the average life expectancy of patients.