Clinical InvestigationImaging and Diagnostic TestingDevelopment of tricuspid regurgitation late after left-sided valve surgery: A single-center experience with long-term echocardiographic examinations
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.
References (25)
- et al.
The necessity for tricuspid valve repair can be determined intraoperatively by two-dimensional echocardiography
J Thorac Cardiovasc Surg
(1987) - et al.
Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis
Am Heart J
(2004) - et al.
Tricuspid valve operations in 530 patients. Twenty-five-year assessment of early and late phase events
J Thorac Cardiovasc Surg
(1990) - et al.
Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction
Am Heart J
(2002) - et al.
Predictors of residual tricuspid regurgitation after mitral valve surgery
Ann Thorac Surg
(2003) - et al.
Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography
J Am Soc Echocardiogr
(2003) - et al.
Mitral, tricuspid, and aortic regurgitation (The Framingham heart study)
Am J Cardiol
(1999) - et al.
Impact of tricuspid regurgitation on long-term survival
J Am Coll Cardiol
(2004) - et al.
Determinants of the severity of functional regurgitation
Am J Cardiol
(2006) - et al.
Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation
Am Heart J
(2006)
Prediction of outcome in patients undergoing surgery for severe tricuspid regurgitation following mitral valve surgery and role of tricuspid annular systolic velocity
Am J Cardiol
Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair
Cardiovasc Surg
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