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J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01. Published in final edited form as: J Thorac Cardiovasc Surg. 2016 March ; 151(3): 796–797. doi:10.1016/j.jtcvs.2015.11.003.
How much is enough to warrant prophylactic tricuspid repair? J. Hunter Mehaffey, MD and Irving L. Kron, MD Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
Author Manuscript
We congratulate Lee and colleagues1 on an interesting and thoughtful article that makes several controversial points. There is no dispute about tricuspid valve annulopasty (TAP) during mitral valve replacement (MVR) in patients with severe tricuspid regurgitation (TR), but the proposition of performing a concomitant procedure in a prophylactic setting raises safety concerns. A recent article by our group2 describes increased morbidity and mortality in more than 400 patients with simultaneous mitral and tricuspid valve operations compared with MVR alone. To balance this increased risk it is important to determine the potential benefit; however, Rajbanshi and colleagues3 report minimal progression of TR after MVR or MVR in a large cohort of patients with preoperative moderate or less TR. Lee and colleagues1 present the long-term benefit of prophylactic TAP for patients with moderate or less TR as a major finding with similar short-term adverse events between the TAP and noTAP groups.
Author Manuscript
Atrial fibrillation is a well-know risk factor for TR progression and we commend the authors for including this factor in their analysis. The subgroup analysis demonstrates the benefit of TAP, especially in patients in sinus rhythm, to prevent recurrence of moderate or greater TR. The authors also highlight the importance of the maze procedure in improving outcomes in patients undergoing MVR with preoperative atrial fibrillation either with or without TAP. Overall, the authors do an excellent job of identifying factors associated with development of late TR-related complications.
Author Manuscript
The surgical procedure is described as if every patient underwent exploration of the tricuspid valve and only those without dilatation did not undergo TAP. This leads one to believe that the lack of dilatation guarantees future tricuspid valve competence. Dreyfus and colleagues4 have shown that tricuspid dilation is an ongoing disease process that will, with time, lead to severe TR. For this reason it is critical to identify patients who will benefit from TAP to ameliorate long-term tricuspid valve-related events such as reoperation for TR, right heart failure, and pacemaker insertion. Lee and colleagues1 do not address this specific issue. The authors do not mention why TAP was done in some patients and not in others. Whether this was surgeon-dependent or dictated by other patient factors not mentioned, and this omission results in major selection bias that must be taken into consideration when evaluating the relevance of this research. Additionally, the authors report limited follow-up
Address for reprints: Irving L. Kron, MD, Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Virginia, Box 800679, Charlottesville, VA 22903 ([email protected]). Disclosures: Authors have nothing to disclose with regard to commercial support.
Mehaffey and Kron
Page 2
Author Manuscript
echocardiographic data. This also contributes to the sampling bias affecting long-term outcomes. The patients described do have long median follow-up, but there is not consistent data on the long-term valve function after the operations. Finally, the end result was reduced progression to late TR but no clinical differences. Is that enough to warrant prophylactic tricuspid repair? In conclusion, the study by Lee and colleagues1 is an interesting retrospective analysis of the effect of TAP at the time of MVR with mechanical heart valves. Unfortunately this study raises numerous questions that cannot be adequately answered by propensity matching. The Cardiothoracic Surgery Network has proposed a randomized trial of prophylactic tricuspid repair to definitively answer this important clinical question. Studying this issue in a randomized, prospective fashion will remove the selection bias and standardize the followup regarding tricuspid function for patients undergoing mitral valve operation.
Author Manuscript
References 1. Lee H, Sung K, Kim WS, Lee YT, Park SJ, Carriere KC, et al. Clinical and hemodynamic influences of prophylactic tricuspid annuloplasty in mechanical mitral valve replacement. J Thorac Cardiovasc Surg. In press. 2. LaPar DJ, Mulloy DP, Stone ML, Crosby IK, Lau CL, Kron IL, et al. Concomitant tricuspid valve operations affect outcomes after mitral operations: a multiinstitutional, statewide analysis. Ann Thorac Surg. 2012; 94:52–7. discussion 58. [PubMed: 22607786] 3. Rajbanshi BG, Suri M, Nkomo VT, Dearani JA, Daly RC, Burkhart HM, et al. Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation. J Thorac Cardiovasc Surg. 2014; 148:1957–62. [PubMed: 24867302] 4. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg. 2005; 79:127–32. [PubMed: 15620928]
Author Manuscript
Biography
Author Manuscript J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01.
Mehaffey and Kron
Page 3
Author Manuscript
Central Message This article discusses prophylactic tricuspid annuloplasty during mitral valve replacment and the need for randomized trials.
Author Manuscript Author Manuscript Author Manuscript J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01.
J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01. Published in final edited form as: J Thorac Cardiovasc Surg. 2016 March ; 151(3): 796–797. doi:10.1016/j.jtcvs.2015.11.003.
How much is enough to warrant prophylactic tricuspid repair? J. Hunter Mehaffey, MD and Irving L. Kron, MD Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
Author Manuscript
We congratulate Lee and colleagues1 on an interesting and thoughtful article that makes several controversial points. There is no dispute about tricuspid valve annulopasty (TAP) during mitral valve replacement (MVR) in patients with severe tricuspid regurgitation (TR), but the proposition of performing a concomitant procedure in a prophylactic setting raises safety concerns. A recent article by our group2 describes increased morbidity and mortality in more than 400 patients with simultaneous mitral and tricuspid valve operations compared with MVR alone. To balance this increased risk it is important to determine the potential benefit; however, Rajbanshi and colleagues3 report minimal progression of TR after MVR or MVR in a large cohort of patients with preoperative moderate or less TR. Lee and colleagues1 present the long-term benefit of prophylactic TAP for patients with moderate or less TR as a major finding with similar short-term adverse events between the TAP and noTAP groups.
Author Manuscript
Atrial fibrillation is a well-know risk factor for TR progression and we commend the authors for including this factor in their analysis. The subgroup analysis demonstrates the benefit of TAP, especially in patients in sinus rhythm, to prevent recurrence of moderate or greater TR. The authors also highlight the importance of the maze procedure in improving outcomes in patients undergoing MVR with preoperative atrial fibrillation either with or without TAP. Overall, the authors do an excellent job of identifying factors associated with development of late TR-related complications.
Author Manuscript
The surgical procedure is described as if every patient underwent exploration of the tricuspid valve and only those without dilatation did not undergo TAP. This leads one to believe that the lack of dilatation guarantees future tricuspid valve competence. Dreyfus and colleagues4 have shown that tricuspid dilation is an ongoing disease process that will, with time, lead to severe TR. For this reason it is critical to identify patients who will benefit from TAP to ameliorate long-term tricuspid valve-related events such as reoperation for TR, right heart failure, and pacemaker insertion. Lee and colleagues1 do not address this specific issue. The authors do not mention why TAP was done in some patients and not in others. Whether this was surgeon-dependent or dictated by other patient factors not mentioned, and this omission results in major selection bias that must be taken into consideration when evaluating the relevance of this research. Additionally, the authors report limited follow-up
Address for reprints: Irving L. Kron, MD, Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Virginia, Box 800679, Charlottesville, VA 22903 ([email protected]). Disclosures: Authors have nothing to disclose with regard to commercial support.
Mehaffey and Kron
Page 2
Author Manuscript
echocardiographic data. This also contributes to the sampling bias affecting long-term outcomes. The patients described do have long median follow-up, but there is not consistent data on the long-term valve function after the operations. Finally, the end result was reduced progression to late TR but no clinical differences. Is that enough to warrant prophylactic tricuspid repair? In conclusion, the study by Lee and colleagues1 is an interesting retrospective analysis of the effect of TAP at the time of MVR with mechanical heart valves. Unfortunately this study raises numerous questions that cannot be adequately answered by propensity matching. The Cardiothoracic Surgery Network has proposed a randomized trial of prophylactic tricuspid repair to definitively answer this important clinical question. Studying this issue in a randomized, prospective fashion will remove the selection bias and standardize the followup regarding tricuspid function for patients undergoing mitral valve operation.
Author Manuscript
References 1. Lee H, Sung K, Kim WS, Lee YT, Park SJ, Carriere KC, et al. Clinical and hemodynamic influences of prophylactic tricuspid annuloplasty in mechanical mitral valve replacement. J Thorac Cardiovasc Surg. In press. 2. LaPar DJ, Mulloy DP, Stone ML, Crosby IK, Lau CL, Kron IL, et al. Concomitant tricuspid valve operations affect outcomes after mitral operations: a multiinstitutional, statewide analysis. Ann Thorac Surg. 2012; 94:52–7. discussion 58. [PubMed: 22607786] 3. Rajbanshi BG, Suri M, Nkomo VT, Dearani JA, Daly RC, Burkhart HM, et al. Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation. J Thorac Cardiovasc Surg. 2014; 148:1957–62. [PubMed: 24867302] 4. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg. 2005; 79:127–32. [PubMed: 15620928]
Author Manuscript
Biography
Author Manuscript J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01.
Mehaffey and Kron
Page 3
Author Manuscript
Central Message This article discusses prophylactic tricuspid annuloplasty during mitral valve replacment and the need for randomized trials.
Author Manuscript Author Manuscript Author Manuscript J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2017 March 01.
