Controversial information
Despite the accumulated information reported, recent articles have
presented opposite results. In a single-center retrospective cohort of
312 patients undergoing MV repair for degenerative diseases, David et
al. demonstrated no association between tricuspid annulus size and
subsequent FTR development, with a low rate of postoperative TR (at 7
years follow-up) in patients presenting annulus size < 40mm
(6.8%, 95% CI 4.6%. – 10.4%), but also in those with annulus ≥ 40mm
(6.0%, 95% CI 2.9% – 12.2%)23. The limitation of
this study is that tricuspid annular size was measured intraoperatively,
using transesophageal echocardiogram (TEE) under general anesthesia,
while the current guidelines are based on TTE or direct intraoperative
measurement. Regardless this limitation, TR prevalence was similar to
that previously described by Rajbanshi et al., in whose study only 6%
of patients developed severe TR at 5-year follow-up after MV repair or
replacement24.
Furthermore, no advantage in terms of TV reoperation rate (HR 0.46; 95%
CI 0.10 ‒ 2.07; p=0.31); congestive heart failure (HR 1.12; 95% CI 0.37
‒ 3.36; p=0.84); and death (HR 1.41; 95% CI 0.82 ‒ 2.42; p=0.22) when
mild-to-moderate FTR was concomitantly managed was suggested by Ro et
al.25.
In terms of possible disadvantages of combined procedures, although
prophylactic TV repair has not been associated with increased mortality
rate, some authors have suggested association with longer operative
times26, higher pacemaker rates27and longer hospital length of stay28.
Additional data comes from the results of a single-center prospective
randomized trial published in 2019. In this study, prophylactic
tricuspid annuloplasty performed concomitantly to MV repair in patients
with less-than-severe FTR was able to reduce FTR recurrence, but did not
affect functional capacity or right ventricular remodeling. Five-year
freedom from cardiac-related mortality was similar in TV treated and
non-treated patients (94.1 ± 3.2% in treated-group vs. 89.7 ± 4.3% in
TV non-treated; p=0.9)29.
When this new study was included in a meta-analysis, however, the
conclusions went in the opposite direction. TV repair was associated
with lower cardiovascular mortality, all-cause mortality and TR
progression over a median of 5.3 years of follow-up (cardiovascular
mortality: RR 0.46, 95% CI 0.28 ‒ 0.75; p=0.002; all-cause mortality:
RR 0.68, 95% CI 0.49 ‒ 0.96; p=0.03; TR progression: RR 0.26, 95% CI
0.12 ‒ 0.56; p<0.001)30. Likewise, when the
prevalence of TR after MV repair due to leaflet prolapse at a more
extended follow-up are evaluated, even David et al. showed numbers that
are more concerned. A 20.8% probability of persistent or new moderate
or severe TR at 20 years made the author point that maybe a much longer
follow-up that those previously reported is needed to observe changes in
tricuspid annulus diameter31.