Prophylactic tricuspid intervention
Carpentier was one of the first authors to recommend tricuspid annular
dilation as a more objective parameter to indicate TV repair. His
evaluation method consisted in TV surgical exploration, checking the
annulus ability to admit three fingerbreadths of the surgeon’s hand, in
which case TV repair would be indicated16.
Three decades later, Dreyfus et al. evaluated tricuspid annuloplasty
performed concomitantly with MV surgery in the presence of
intraoperative tricuspid annular diameter ≥ 70mm, measured from the
anteroseptal commissure to the anteroposterior commissure, regardless
the preoperative TR grade. In a 5-year follow-up, TR degree, as well as
patients’ functional status, was significantly lower in the TV treated
group10.
Regarding echocardiographic measurement, evaluating 50 patients
submitted to MV replacement due to rheumatic disease, Colombo et at.
suggested that tricuspid annulus diameter > 21
mm/m2 could be a reliable parameter to indicate
concomitant TV repair in this specific patient
population17.
Similarly, using a tricuspid annulus dimension ≥ 40mm (>
21mm/m2) measured preoperatively in transthoracic
echocardiography (TTE) 4-chamber view as a cut-off to indicate
concomitant TR intervention, Van deVeire et al. demonstrated better
reverse right ventricular remodeling and less postoperative TR
prevalence, when compared with isolated MV surgery18.
Figure 1 illustrates echocardiographic tricuspid valve evaluation, and
Figure 2 a TR surgical repair using an annuloplasty ring.
In 2012, Benedetto et al. conducted a randomized trial enrolling 44
patients with less-than-severe TR (≤ + 2) and annular dilatation (≥
40mm) treated at the same time that MV surgery. Early results
demonstrated the safety of the combined approach (1 case of 30-day
mortality in each group), with just a discreet increase in
cardiopulmonary bypass and aortic cross-clamping time. After 12 months,
those patients who underwent TV intervention presented with significant
TR reduction (TR absent in 71% vs. 19%; p=0.001), improvement in
functional capacity (6 min walking test: +115 ± 23m vs. +75 ± 35m;
p=0.008), and right ventricular reverse remodeling [right ventricle
long-axis 71 ± 7mm preoperative vs. 65 ± 8mm postoperative
(p<0.01) and short-axis 33 ± 4mm preoperative vs. 27 ± 5mm
postoperative (p=0.01) in TV treated group; right ventricle long-axis 72
± 6mm preoperative vs. 70 ± 7mm postoperative (p=0.08), and short-axis
34 ± 5mm preoperative vs. 33 ± 5mm postoperative (p=0.1) in TV
non-treated group]19.
Two-years after this publication, Chikwe et al. tested the association
of an aggressive concomitant prophylactic TV repair (annular dilatation
≥ 40mm or ≥ moderate TR) in patients undergoing MV repair for
degenerative diseases. No increased 30-day mortality and morbidity,
lower TR progression rate, reduced pulmonary hypertension and
improvement in induced right ventricle recovery were observed at 7-year
follow-up20.
Regarding guideline recommendations, the American Heart
Association/American College of Cardiology and the European Society of
Cardiology/European Association for Cardio-Thoracic Surgery have
recommended TR repair concomitant with left-sided surgery in the
presence of annular size ≥ 40mm (>
21mm/m2), regardless of TR degree, as a Class IIa of
recommendation21,22, which still means a low level of
evidence.