Study: Tricuspid annuloplasty with mitral replacement appeared safe and effective

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Combined TAP-MVR ‘plausible’

The proposition of performing a concomitant TAP during MVR to prevent late progression of tricuspid regurgitation (TR) “raises safety concerns, Dr. J. Hunter Mehaffey and Dr. Irving L. Kron of the University of Virginia, Charlottesville, said in their invited commentary (J. Thorac. Cardiovasc. Surg. 2016;151:796-7). They cited their own study of 400 patients that reported higher death and complication rates in concomitant TAP-MVR procedures than in MVR alone (Ann. Thorac. Surg. 2012;52-8).

M. Alex Otto/Frontline Medical News

Dr. Hunter Mehaffey

While Dr. Mehaffey and Dr. Kron commended Dr. Lee and colleagues for including atrial fibrillation in their risk analysis, they also questioned why the investigators did not address how to identify patients who would benefit from TAP to reduce the potential for long-term tricuspid, valve-related problems like reoperation for TR, right heart failure and pacemaker insertion. Nor do the investigators explain why they performed TAP in some patients and not others.

They called the study by Dr. Lee and colleagues an “interesting retrospective analysis” of concomitant TAP with MVR. “Unfortunately, this study raises numerous questions that cannot be adequately answered by propensity matching,” the coauthors wrote. A randomized, prospective trial would resolve many of these issues, they said.

Dr. Mehaffey and Dr. Kron had no financial relationships to disclose.




Controversy has surrounded the idea of concomitant tricuspid annuloplasty (TAP) with mitral valve surgery (MVR) as a way to prevent further progression of tricuspid regurgitation, and while several reports have suggested the procedures can be done safely and effectively, few reports have explored the idea of concomitant procedures in people with moderate or mild tricuspid regurgitation (TR) as a measure to prevent progression to more severe TR.

But investigators at Sungkyunkwan University in Seoul have found that TAP at the same time as MVR can be done without increasing surgical risks for patients, according to a report in the March issue of the Journal of Thoracic and Cardiovascular Surgery (2016;151:788-95).

“Although prophylactic TAP showed marginal clinical benefits for patients with less than moderate TR, we believe it is plausible to anticipate a long-term trend of a benefit of TAP in longer-term follow-up studies,“ Dr. Heemoon Lee and coauthors wrote. “Many other longer-term prospective randomized studies are needed to confirm our study findings and to ascertain clinical benefits of prophylactic TAP during mitral valve surgery.”

Despite existing clinical guidelines that recommend tricuspid valve repair for severe TR associated with mitral valve disease that requires MVR, prophylactic TAP for patients with less than moderate TR at the time of left-side valve surgery remains controversial because TR has been linked to multiple complex factors. They include etiology, whether degenerative or rheumatic; concomitant atrial fibrillation (AF); unreliable TR grading; or measurement of tricuspid annular diameter.

The investigators performed primary mechanical MVR on two groups of patients between November 1994 and December 2010: 151 with TAP; and 142 without TAP. All operations were performed through a standard median sternotomy and median follow-up was 107 months.

They looked at both early and late outcomes. There was no early mortality in either group; two bleeding episodes that required further surgery and one pacemaker insertion in the no-TAP group; and no bleeding complications and heart blocks requiring pacemaker insertion in the TAP group. While ICU stays were similar for both groups, the TAP group had significantly shorter hospital stays: 9 days vs. 11 days (P less than .001).

In terms of overall and cardiac-related deaths at 10 years, the investigators reported no significant differences between the two groups. “TAP did not appear to improve cardiac-related mortality,” Dr. Lee and coauthors said. Nor did freedom from tricuspid valve–related events differ appreciably between the two groups: 84.8% in TAP and 77.5% in no-TAP at year 10 (P = .087).

But the TAP group showed far lower rates of progression to late TR at 10 years – one in the TAP group; one (less than 1%) vs. nine (6.3%) in the no-TAP group; 96.8% in the TAP group were free from TR recurrence of grade 2 or greater vs. 85.6% in no-TAP.

“TAP can be performed safely without increases in early mortality and morbidities, including heart block,” Dr. Lee and coauthors said. “We also found that prophylactic TAP can prevent progression of late moderate or greater TR. TAP showed a tendency to prevent tricuspid valve–related events and was marginally significant.”

The researchers also evaluated the role of AF as a risk factor for progression of late TR; the effects of TAP on recurrence of moderate or greater TR were “prominent” in patients with sinus rhythm vs. AF at discharge. “These findings may reflect that the maze procedure is more important than prophylactic TAP in improving late outcomes in mitral valve disease with AF,” Dr. Lee and colleagues wrote.

The investigators acknowledged a number of limits of their study: its retrospective nature; how indications and techniques of MVR, TAP, and the maze procedure evolved over the study duration; and that the maze procedure and prophylactic TAP were not widely embraced in the early years of the study.

Dr. Lee and colleagues had no financial relationships to disclose.

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