Clinical Investigation
Imaging and Diagnostic Testing
Development of tricuspid regurgitation late after left-sided valve surgery: A single-center experience with long-term echocardiographic examinations

https://doi.org/10.1016/j.ahj.2007.11.010Get rights and content

Objectives

This study sought to investigate the incidence and identify the predictors of significant tricuspid regurgitation (TR) development long after left-sided valve surgery.

Methods

Of 615 patients who underwent surgery for left-sided valve disease between 1992 and 1995, 335 patients without significant TR who completed at least 5 years of clinical and echocardiographic follow-up were enrolled. Late significant TR development was assessed by echocardiography with a mean follow-up duration of 11.6 ± 2.1 years.

Results

Significant late TR was found in 90 patients (26.9%). Patients with late TR showed an advanced age (47.6 ± 13.4 vs 44.3 ± 13.2 years, P = .04), a higher prevalence of preoperative atrial fibrillation (83.3 vs 46.5%, P < .001), a greater left atrial dimension (56.9 ± 13.2 vs 52.4 ± 11.5mm, P = .006), and a higher prevalence of prior valve surgery (40.0 vs 25.3%, P = .01). In addition, late TR occurred more frequently in patients who had undergone mitral valve surgery than in those who did not (93.3 vs 72.2%, P < .001). However, multivariate analysis showed that the presence of preoperative atrial fibrillation (odds ratio 5.37; 95% CI 2.71-10.65; P < .001) was the only independent factor of late TR development. Patients who developed late TR had a lower event-free survival rate than those who did not (P = .03).

Conclusions

The development of significant TR long after left-sided valve surgery is not uncommon with an estimated incidence of 27% and is closely associated with a poor prognosis. The presence of preoperative atrial fibrillation was identified as the only independent predictor of the development of late TR.

Section snippets

Study population

This study was based on our consecutive experiences of patients who underwent surgical correction for left-sided valve disease from January 1992 to December 1995. During this period, a total of 615 patients underwent surgery for mitral, aortic, or combined mitral/aortic valve disease at our institution, and these were initially considered eligible for this study. However, we excluded patients who underwent combined tricuspid valve replacement (n = 19), aortic surgery (n = 20), correction of

Baseline characteristics

The baseline characteristics of the 335 study subjects are summarized in Table I. Mean follow-up duration was 11.6 ± 2.1 years (range 5.1-14.6 years). Preoperative electrocardiograms showed atrial fibrillation in 189 (56.4%) of the patients.

Mitral valve surgery (mitral valve replacement or mitral valve repair) without accompanying aortic valve surgery was performed in 174 patients (51.9%), aortic valve surgery alone (aortic valve replacement or aortic valve repair) in 74 (22.1%), and combined

Discussion

In the present study, it was found that the incidence of late TR was 26.9% after left-sided valve surgery in patients without preoperative significant TR, and that the incidence of severe TR was 7.5%. Multivariate logistic regression analysis revealed the presence of preoperative atrial fibrillation as the only independent predictor of late TR development, with an approximately 5-fold elevated risk. Furthermore, late TR was found to be accompanied by a lower long-term event-free survival rate.

Conclusions

The de novo development of significant TR long after left-sided valve surgery is not uncommon, with an estimated incidence of 27%, and is closely associated with a poor prognosis. The present study identified preoperative atrial fibrillation as the only independent predictor for the development of late TR. Therefore, tricuspid annuloplasty should be considered in the presence of atrial fibrillation, even in patients' mild TR at the time of surgical correction for left-sided valve disease.

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