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.