Points/Counterpoint: Should surgeons operate on functional tricuspid regurgitation?

June 20, 2017|Cardiology News

David H. Adams, MD;Tirone David, MD;Gilles Dreyfus, MD;And Hartzell Schaff, MD

AT THE AATS MITRAL CONCLAVE 2017

We need a strong debate to agree on those endpoints. Mortality as an endpoint will probably take a very long time to arrive at.

We’re mixing up many different factors. We’re mixing up TR grading, and we know that grading is unreliable. We have all seen patients with full-fledged TR, and after we put them on Lasix (furosemide, Sanofi), 3 days later they have mild TR. So the same patient with no treatment becomes let’s say a “Dreyfus indication,” and then suddenly in 3 days the patient doesn’t need surgery. At any further stage of his life this patient can experience severe TR again; tricuspid annuloplasty will prevent that from happening.

It is a big mistake to rely only on grading to determine the need for surgery to treat FTR. We are superimposing the assessment of the right ventricle (RV) to the left one, but that is mixing apples and pears. The left ventricle (LV) is working against resistances and its volume does not change; the RV supplies only the pulmonary system and is volume-dependent. You can double the size of the RV without changing its function whatsoever, and that’s when TR may appear if all the features are present: annular dilatation and RV dilatation. Any changes in preload such as severe renal failure, as well as any changes in afterload such as moderate LV impairment or mild/moderate MR after MVR, may modify RV size and TR grading.

Moderate TR according to the common definition does not exist. If you look at the reports in echocardiography and if you ask any cardiologist, everything between no TR and severe TR is considered moderate. We have proposed a new staging system for evaluating FTR that uses three factors: TR severity; annular dilatation; and extent of tethering, or mode of leaflet coaptation (J Am Coll Cardiol. 2015;65:2331-6).

Dr. Dreyfus is director of the medical and surgical team at the Cardiothoracic Centre of Monaco in Monte Carlo and professor of cardiothoracic surgery at Paris V University and the Imperial College of London. He disclosed receiving speaker fees from Edwards Lifesciences, LivaNova, and Medtronic.

No, few FTR patients at risk after MVR (Hartzell Schaff, MD)

Echocardiography can provide a great deal of information about when concomitant repair for TR is indicated during MVR. We’ve found that if the patient has no right-sided signs, has normal right atrial pressure, and has mild or mild/moderate TR at the time of repair to the journey mitral valve, the chance of him returning for a tricuspid valve procedure is near zero.

A few patients do return after MVR. They develop atrial fibrillation and may need a pacemaker, but we see very few patients return for tricuspid surgery.

There is a hierarchy of valves: the tricuspid valve; the pulmonary; the aortic valve; and the mitral valve. You can do without the pulmonary valve and live. In fact you can do without a tricuspid valve and live; there was a surgeon that used to do tricuspid valvectomies for endocarditis. You don’t live well; you’ll eventually have to have the tricuspid valve replaced. But you cannot live without a mitral valve and you cannot live without an aortic valve.

It’s fair to say we cannot demonstrate any benefit of correcting functional mitral regurgitation. Why would we think there’s a benefit of correcting FTR? We can say we’re going to look at grade of TR down the road, or we could look at some other endpoint, but think about it this way: If we cannot prove that correcting functional mitral regurgitation is helpful, why is correcting FTR going to help?

Dr. Schaff is a cardiothoracic surgeon at Mayo Clinic Foundation, Rochester, Minn. He reported no financial relationships.