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Archives of cardiovascular diseases
Volume 111, n° 8-9
pages 480-486 (août 2018)
Doi : 10.1016/j.acvd.2017.08.006
Received : 20 Mars 2017 ;  accepted : 27 August 2017
Clinical research

Is tricuspid annuloplasty increasing surgical mortality and morbidity during mitral valve replacement? A single-centre experience
L’annuloplastie tricuspide augmente-t-elle la morbi-mortalité opératoire du remplacement valvulaire mitral – Une étude monocentrique
 

Constance Verdonk a, b, c, Arthur Darmon a, Claire Cimadevilla d, Laurent Lepage d, Richard Raffoul d, Patrick Nataf b, c, d, Alec Vahanian a, b, c, David Messika-Zeitoun a, b, c,
a Department of cardiology, Bichat hospital, AP–HP, Paris, France 
b INSERM U1148, Bichat hospital, Paris, France 
c Faculté de médecine Paris-Diderot, university Paris Diderot, Sorbonne Paris Cité, Paris, France 
d Department of cardiac surgery, Bichat hospital, AP–HP, Paris, France 

Corresponding author at: Cardiovascular division, Bichat hospital, AP–HP, 46, rue Henri-Huchard, 75018 Paris, France.Cardiovascular division, Bichat hospital, AP–HP, 46, rue Henri-Huchard, 75018 Paris, France.
Summary
Background

Performance of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery is recommended based on the degree of tricuspid regurgitation and tricuspid annulus size, but is often underused.

Aim

To evaluate the impact of combined TA on in-hospital outcome in patients undergoing mitral valve replacement (MVR).

Methods

We selected all consecutive patients who underwent MVR for native valve disease. Clinical, echocardiographic and in-hospital complications were obtained from chart review.

Results

We identified 287 patients (mean age 62±17 years; 44% men). Combined TA was performed in 165 patients (57%), who had more rheumatic disease (71% vs. 24%; P <0.0001) and mitral stenosis (55% vs. 22%; P <0.0001), but less endocarditis (4% vs. 31%; P <0.0001), were more often in atrial fibrillation (54% vs. 22%; P <0.0001), were more severely symptomatic (80% vs. 57%; P <0.0001), presented with a higher systolic pulmonary artery pressure (SPAP) (53±16 vs. 45±15mmHg; P =0.0002) and were less likely to have required emergency surgery (17% vs. 38%; P <0.0001). Despite this higher risk profile, in-hospital mortality was slightly lower (5% vs. 13%; P =0.02) and complication rates were similar (redo surgery 22% vs. 16% [P =0.18] and tamponade 20% vs. 15% [P =0.15]). After adjustment for age, sex, functional class, SPAP, emergency surgery and concomitant coronary artery bypass graft or aortic valve replacement surgery, combined TA was not associated with an increased rate of in-hospital death (P =0.08) or major complications (P =0.89).

Conclusions

In a consecutive series of patients who underwent MVR, TA did not seem to have a negative impact on immediate outcome. Hence, additional performance of TA at the time of MVR should not be declined on the basis of an increased surgical risk.

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Résumé
Contexte

Si une annuloplastie tricuspide (AT) est indiquée chez les patients devant bénéficier d’une chirurgie mitrale en cas de fuite tricuspide significative ou de dilatation de l’anneau tricuspide, elle reste sous-utilisée.

But

Le but de la présente étude est d’évaluer l’impact d’une AT réalisée lors d’un remplacement valvulaire mitral (RVM) sur la morbi-mortalité hospitalière.

Méthodes

Nous avons recensé tous les patients consécutifs ayant bénéficiés d’un RVM sur une période de 2 ans dans notre institution et colligés les données cliniques, échographiques et les complications postopératoires.

Résultats

Nous avons identifié 287 patients (62±17 ans ; 44 % homme). Les patients chez qui une AT a été réalisée (n =165, 57 %) présentaient plus souvent une étiologie rhumatismale (71 % vs 24 % ; p <0,0001), une sténose mitrale (55 % vs 22 % ; p <0,0001) mais moins fréquemment une endocardite (4 % vs 31 % ; p <0,0001) était plus souvent en fibrillation auriculaire (54 % vs 22 % ; p <0,0001), plus sévèrement symptomatiques (80 % vs 57 % ; p <0,0001) et présentaient une pression artérielle pulmonaire (PAPS) plus élevée (53±16mmHg vs 45±15mmHg ; p =0,0002). Malgré une présentation plus sévère, la mortalité hospitalière était discrètement inférieure (5 % vs 13 % ; p =0,02) et le taux de complication non significativement diffèrent (ré-intervention 22 % vs 16 % [p =0,18] ou tamponade 20 % vs 15 % [p =0,15]). Après ajustement pour l’âge, le sexe, la classe fonctionnelle, la PAPS, le degré d’urgence de la chirurgie et la réalisation d’un pontage ou d’un remplacement valvulaire aortique associé, la réalisation d’un AT n’était ni associée à une augmentation de la mortalité (p =0,08) ni à un taux plus élevé de complications sévères (p =0,89).

Conclusions

Dans cette série consécutive de patients opérés pour RVM, la réalisation d’un AT n’était pas associée à une augmentation du risque de complications post-opératoires. Ces résultats montrent que la crainte d’une augmentation du risque opératoire ne doit pas conduire a récuser la réalisation d’une AT si celle-ci est indiquée.

The full text of this article is available in PDF format.

Keywords : Tricuspid regurgitation, Tricuspid annuloplasty, Mitral valve replacement

Mots clés : Insuffisance tricuspide, Annuloplastie tricuspide, Remplacement valvulaire mitral

Abbreviations : AF, AVR, CABG, LVEF, MVR, SPAP, TA, TR


Background

Concomitant tricuspid valve abnormalities are commonly observed in patients with mitral valve disease [1, 2]. According to current European and North American guidelines, tricuspid surgery—mainly tricuspid annuloplasty (TA)—is recommended at the time of mitral valve surgery in patients with moderate-to-severe tricuspid regurgitation (TR) or with significant enlargement of the tricuspid annulus diameter (>40mm or 21mm/m2) [3, 4]. Combined or concomitant tricuspid surgery aims to cure TR or to prevent the occurrence of late severe TR. Severe TR is an independent prognostic factor [5, 6]; the occurrence of late severe TR is not rare and is associated with poor outcome, and in-hospital mortality for isolated TR surgery is close to 10% [7, 8, 9, 10]. Nevertheless, tricuspid abnormalities are commonly neglected, and combined tricuspid at the time of the mitral valve surgery is consequently underused. Indeed, severe TR has a falsely benign reputation, and right-side abnormalities are thought to be cured after correction of the left side. In addition, the performance of combined tricuspid surgery has been deemed to increase surgical morbidity and mortality.

To specifically assess the potential additional risk associated with the performance of TA, we reviewed all consecutive patients who underwent mitral valve replacement (MVR) at our institution, and compared in-hospital mortality and morbidity between patients who did and did not undergo combined TA.

Methods
Population

We enrolled all consecutive patients who underwent MVR between January 2013 and December 2014 at our institution. Patients with a history of cardiac surgery (mitral or other) and patients who underwent mitral valve repair or tricuspid valve replacement were excluded. Data on medical history, especially history of stroke, atrial fibrillation (AF), renal and respiratory failure and coronary artery disease, cardiovascular risk factors and functional status according to the New York Heart Association were collected retrospectively. Renal insufficiency was defined as an estimated glomerular filtration rate<60mL/min/1.73m2, according to the Cockcroft formula. A history of coronary disease was defined by a previous myocardial infarction and/or coronary angioplasty. The decision to perform TA was made by the physicians in charge of the patients, based on TR degree and size of the tricuspid annulus, as recommended. Emergency surgery was defined as an intervention occurring within 7 days after admission. In-hospital mortality and postoperative events, such as pericardial effusion, surgical drainage for tamponade, occurrence of new postoperative AF, bleeding requiring transfusion (more than two packs), prolonged inotropic support (need of intravenous inotropic support for>24 postoperative hours) and length of stay, were collected based on chart review. The study was approved by our institutional local review board.

Echocardiographic assessment

Transthoracic echocardiography was performed for all patients before surgery, usually combined with transoesophageal echocardiography. The aetiology of the mitral valve disease was categorized as rheumatic, degenerative, infective endocarditis or other. Left ventricular ejection fraction (LVEF) was assessed according to the Simpson method or visually, and was considered normal when50%. Systolic pulmonary artery pressure (SPAP) was calculated using continuous wave Doppler of the TR jet (in the absence of laminar flow) and estimation of right atrial pressure based on inferior vena cava size. TR was graded in four grades, according to the European guidelines for management of valvular heart disease [11]. The tricuspid annulus diameter was measured in the four-chamber view in diastole [12, 13].

Statistical analysis

Continuous variables are expressed as mean±standard deviation or median and 95% confidence interval in case of non-normal distribution; categorical variables are expressed as number (percentage) of patients. Comparison of baseline characteristics and postoperative outcomes between patients who did and did not undergo combined TA was performed using the t test, the Wilcoxon test or analysis of variance, as appropriate. Logistic regressions in multivariable analysis overall and in different subsets were used to assess the impact of combined TA on in-hospital death or major complications (death, redo surgery, tamponade or prosthesis thrombosis). Data were analysed with JMP software, version 9.0 (SAS Institute, Cary, NC, USA), and a P -value<0.05 was considered statistically significant.

Results
Baseline characteristics

During the 2-year period, 287 patients underwent a first MVR at our institution. Baseline characteristics of the population are presented in Table 1. The mean age was 62±17 years, 125 patients (44%) were men and 116 patients (40%) had a history of AF. Most of the patients were severely symptomatic, in New York Heart Association functional class III/IV (n =201, 70%). Mitral insufficiency was the main indication for surgery (n =161, 56%), and the main aetiology of the mitral valve disease was rheumatic (n =146, 51%). Eleven patients presented with functional mitral regurgitation (4%). Only 34 patients (12%) had a reduced LVEF. Moderate-to-severe TR was observed in 97 patients (34%). The mean tricuspid annulus diameter was 41±7mm, and the mean SPAP was 50±16mmHg.

Surgery and postoperative outcome

Surgical characteristics and complications rates are presented in Table 2. Mean extracorporeal circulation time was 92±34minutes, and the aortic cross-clamping time was 71±30minutes. A mechanical prosthesis was implanted in 185 patients (64%), and a bioprosthesis in 102 patients (36%). Emergency surgery was required in 75 patients (26%), whereas the rest of the population underwent elective surgery. The duration of in-hospital stay was 20±18 days (median 17 days, 95% confidence interval 11–24 days).

Twenty-five patients (9%) died during the postoperative period. The main causes of death were cardiogenic shock in seven patients (28%), septic shock in seven patients (28%) and left ventricle rupture in four patients (16%). Pericardial effusion was the main postoperative complication, occurring in 119 patients (41%). A redo surgery was required in 55 patients (19%), mostly for tamponade (n =51, 18%). A prosthesis thrombosis was observed in 19 patients (7%), but only three patients (1%) had to be reoperated on. We observed 85 cases of new postoperative AF (30%). Overall, 86 patients (30%) experienced a major complication (redo surgery, tamponade, prolonged inotropic support, new AF).

Comparison of baseline characteristics between patients who did and did not undergo combined TA

Combined TA (Carpentier ring) was performed in 165 patients (57%). A comparison of baseline characteristics between patients with and without combined TA is presented in Table 1. Briefly, patients who underwent combined TA were more frequently women (64% vs. 47%; P =0.02), were more often in AF (54% vs. 22%; P <0.0001), severely symptomatic (80% vs. 57%; P <0.0001), with a higher SPAP (53±16 vs. 45±15mmHg; P =0.0002), but presented less frequently with a history of coronary artery disease (4% vs. 12%; P =0.02). They were also more often operated on for mitral stenosis (55% vs. 22%; P <0.0001) and the aetiology of the mitral valve disease was more frequently rheumatic (71% vs. 24%; P <0.0001) and less frequently infective endocarditis (4% vs. 31%; P <0.0001). As expected, moderate-to-severe TR was more frequent (48% vs. 15%; P <0.0001) and the tricuspid annulus diameter was larger (42±7 vs. 38±6mm; P =0.0001). LVEF was also more often reduced in patients who underwent combined TA (15% vs. 7%; P <0.05).

Comparison of in-hospital complications between patients who did and did not undergo combined TA

A bioprosthesis was more frequently implanted in patients who underwent combined TA (42% vs. 27%; P =0.01). Extracorporeal circulation time (94±32 vs. 89±36min; P =0.26) and aortic cross-clamping time (72±28 vs. 70±33min; P =0.63) were not different between patients who underwent combined TA and those who did not. However, extracorporeal circulation time (82±22 vs. 71±26min; P =0.003) and aortic cross-clamping time (61±20 vs. 52±20min; P =0.006) were slightly longer after exclusion of the 103 patients (36%) who underwent concomitant coronary artery bypass graft (CABG) or aortic valve replacement (AVR), which was less commonly performed in patients with combined TA (32% vs. 42%; P =0.07).

Complication rates are presented in Table 2. The death rate was lower in patients who underwent combined TA than in patients who did not (5% vs. 13%; P =0.02). The rates of other complications were not different between groups (all P >0.05), except for the rate of bleeding, which was lower in the combined TA group. The rates of major complications (31% vs. 29%; P =0.68) and the in-hospital lengths of stay (21±16 days vs. 20±20 days; P =0.33) were similar. The rates of major complications were also similar when patients who underwent combined TA on the basis of TA size alone (without significant TR) were excluded (33% vs. 29%; P =0.51).

In the multivariable analysis, after adjustment for age, sex, functional status, emergency surgery and concomitant CABG or AVR, TA was not associated with increased rates of death (P =0.08) or major complications (combination of death, redo surgery, tamponade and prosthetic thrombosis) (P =0.89). The same results were obtained when the analysis was restricted to the 135 patients who underwent elective surgery without concomitant CABG or AVR (P =0.11 for death and P =0.13 for major complications). Excluding patients with moderate or severe TR did not change these findings (P =0.64 for death and P =0.68 for major complications).

Discussion

In 287 consecutive patients without previous cardiac surgery who underwent MRV at our institution over a 2-year period, we evaluated the impact of the performance of combined TA on the incidence of in-hospital death and complications. TA was performed in more than half of the patients. Although these patients presented with a higher risk profile, additional performance of TA was not associated with an increased risk of death and complications overall or after exclusion of patients who underwent emergency surgery or were operated on for infective endocarditis. Our results strongly suggest that adding TA at the time of MVR does not increase the risk of in-hospital death or complications.

Functional TR is commonly observed in patients with mitral valve disease [1, 2]. TR has long been considered a benign finding that can be neglected. However, the literature provides strong evidence that not only is the presence and degree of TR a marker of more severe/advanced disease, but severe TR, by itself, negatively impacts outcome [5, 6, 14, 15]. There is currently little debate regarding correction of severe TR at the time of mitral valve surgery. Lesser TR degree or absence of TR may seem reassuring, but the literature is also concordant in showing that up to 30% of patients may develop late significant TR, which is associated with a worse outcome [16, 17, 18]. In most cases, correction of left-sided disease is insufficient to correct tricuspid abnormalities [19, 20], and even in the absence of TR, tricuspid annulus enlargement exposes patients to a high risk of late severe TR. Observational series have shown that concomitant tricuspid surgery is associated with reverse right ventricular remodelling and a better outcome [21, 22, 23]. Based on these outcome studies, TA is recommended in patients with moderate-to-severe TR or tricuspid enlargement [3, 4]. Thresholds of 40mm or 21mm/m2 of body surface area for the tricuspid annulus diameter have been proposed, even if the level of evidence remains low and controversial [24, 25, 26, 27, 28]. However, although rates and predictors of significant late TR have been identified, performance of TA at the time of mitral valve surgery remains underused. Potential reasons are the benign TR reputation, the misplaced belief that tricuspid abnormalities will either regress or remain stable after correction of left-sided disease, or the belief that addition of TA increases the surgical risk.

To address this last issue, we reviewed all consecutive patients who underwent MVR (with no previous cardiac surgery) at our institution over a 2-year period. The decision to perform combined TA was made by the attending physicians, based on TR degree and size of the tricuspid annulus diameter. Combined TA was performed in more than half of the patients. The high rate of combined TA is probably related to our specific recruitment and the high incidence of rheumatic disease. As expected, patients who underwent combined TA had a more severe risk profile: they presented more often in AF, were in a higher functional class and had a higher SPAP. In contrast, TA was less commonly performed in case of emergency surgery or infective endocarditis. The main result of the present study is to show that during MVR, TA was not performed at the expense of an increase in the rate of adverse events. After adjustment for age, sex, functional class, SPAP, concomitant CABG or AVR and emergency surgery, TA was not associated with an increased risk of in-hospital death or complications. Thus, our results support the use of combined TA at the same time as MVR, when clinically indicated.

The present study deserves several comments. Firstly, it was a single-centre observational study. However, a relatively large number of consecutive patients were enrolled, and endpoints were easy to ascertain. It is also worth noting that all patients underwent the same surgical procedure, using a tricuspid Carpentier-Edwards ring. Secondly, we only considered patients who underwent MVR, a situation often associated with presentation of more advanced disease and a higher risk of late TR. The benefit of combined TA in patients with degenerative leaflet prolapse is debated [26, 27, 28], and the impact of combined TA on in-hospital mortality and morbidity during mitral valve repair deserves specific investigation. Thirdly, the performance of TA was based on TR degree or TA size, and the final decisions were made by the physicians in charge of the patients; thus, the groups with and without combined TA presented significant differences. However, imbalance in risk profile was in favour of the group who did not undergo TA, and we performed a multivariable analysis and subgroup analyses confirming that TA did not add to the surgical risk. Fourthly, we did not have systematic follow-up echocardiograms to assess recurrence or increase in degree of TR. However, the goal of the present study was not to evaluate whether TA prevents TR progression. Finally, our aim was not to validate the indications for TA or the thresholds proposed in current guidelines and their beneficial impact on outcome, but to evaluate whether the performance of TA increases the surgical risk. Future randomized control trials, such as the one proposed by the Cardiothoracic Surgical Trials Network (CTSN), will hopefully address this issue specifically.

Conclusions

In a large consecutive series of patients who underwent MVR, combined TA, performed in more than half of the population, was not associated with increased rates of in-hospital mortality or in-hospital complications. Thus, the decision to perform TA at the time of MVR should not be declined on the basis of an increased surgical risk. Future randomized controlled trials will further refine clinical indications and impact on long-term outcome.

Sources of funding

None.

Disclosure of interest

The authors declare that they have no competing interest.

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