A new study published in the New England Journal of Medicine suggests that patients with mitral and tricuspid valve regurgitation (TR), who underwent tricuspid valve annuloplasty during mitral valve surgery lowered their risk for progression of TR with improved outcomes at two years. These results were presented at the virtual American Heart Association (AHA) Scientific Sessions 2021.

The Cardiothoracic Surgical Trials Network (CTSN) researchers recruited 401 patients (mean age 67 years) with either moderate TR (37%) or less than moderate TR with a dilated tricuspid annulus (≥40 mm or index: ≥21 mm/m² body surface area). They were randomized to undergo either mitral valve surgery alone (n = 203) or mitral valve surgery + tricuspid valve annuloplasty (n = 198), at different hospitals in the United States, Germany and Canada. Seventy-five percent of the participants were men. The primary endpoint (failure of treatment) was a composite of tricuspid valve reoperation, progression of TR to severe grade or by two or more grades or death at two years.

The CTCR-MVS trial showed that the primary endpoint events ((death, tricuspid valve reoperation, TR progression by at least 2 grades) were higher in patients who underwent mitral valve surgery alone vis à vis those who underwent both mitral valve surgery and tricuspid annuloplasty; 10.2% versus 3.9%; respectively. None of the patients, in either group, required tricuspid valve reoperation.

They also had higher mortality rate (4.5%) as compared to the mitral valve surgery plus tricuspid annuloplasty patients (3.2%). The relative risk was 0.69. Rate of progression of TR to more severe grade at two years was higher in the surgery-alone patients (6.1%) than in patients who had both procedures (0.6%) with a relative risk of 0.09.

No between-group differences were observed at two years with respect to major adverse cardiac and cerebrovascular events, functional status and quality of life. But 14.1% of patients who underwent simultaneous tricuspid annuloplasty needed a permanent pacemaker compared to 2.5% of mitral valve surgery alone patients (relative risk 5.75).

Tricuspid annuloplasty at the time of mitral valve surgery in patients with mild to moderate TR decreased treatment failure. According to the authors, this was primarily due to reduction in progression of TR to a more severe category. However, this reduction in risk of progression of TR was associated with an increased risk of the need for a permanent pacemaker. Decision-making therefore has to be individualized for each patient. A long-term follow-up of trial participants will help determine the “net clinical benefit”, say the authors.

Reference

1. Gammie JS, et al; CTSN Investigators. Concomitant tricuspid repair in patients with degenerative mitral regurgitation. N Engl J Med. 2021 Nov 13.  doi: 10.1056/NEJMoa2115961.