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1
==Abstract==
2
3
====Background====
4
5
Functional tricuspid regurgitation (FTR) is frequent in patients with mitral valve disease. Untreated tricuspid regurgitation (TR) may cause poor clinical outcomes. The surgical factors involved in annuloplasty for FTR remain controversial. Our objective was to compare effectiveness of different tricuspid annuloplasty (TVP), and reveal the risk factors of recurrence.
6
7
====Methods====
8
9
We analyzed the clinical details of 399 consecutive patients who underwent mitral surgery with concomitant TVP, from 2006 to 2011, in two Chinese single-centers. Three methods were used for TVP: De Vega surgery was completed in 242 patients; annuloplasty using a flexible band was completed in 98 patients; and surgery with a rigid ring was performed in 59 patients.
10
11
====Results====
12
13
The operative mortality rate was 2.3%. After surgery, the TR grade of all patients decreased significantly. At three years postoperatively, 13.7% of patients were diagnosed with recurrent FTR. At the three year time point, severe TR in the De Vega group was 18%, which was higher than those in the flexible (8.4%) and rigid planner ring groups (5.2%). During follow-up, the recurrent rates in the rigid group were significantly lower than in the flexible group. Multivariate analysis revealed that pre-operative atrial fibrillation, severe TR, large left atrial, ejection fraction (EF) < 40%, De Vega annuloplasty, and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.
14
15
====Conclusions====
16
17
Rigid ring annuloplasty efficaciously improved post-operative tricuspid valve function in patients with FTR. Atrial fibrillation, a large left atrium, low EF and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.
18
19
==Keywords==
20
21
Functional tricuspid regurgitation;Tricuspid annuloplasty;Follow-up
22
23
==1. Background==
24
25
Tricuspid regurgitation (TR) is always present in patients with mitral valve (MV) disease, and over one-third of the patients with mitral stenosis have at least moderate TR [[#bb0005|[1]]]. Patients with pre-operative severe TR have severe MV disease, higher pulmonary vascular resistance, and poorer outcomes. The functional label referring to TR, which is secondary to either left-sided heart disease (LHD) or pulmonary hypertension, could be possibly a misnomer [[#bb0010|[2]]]. If untreated at the time of MV surgery, TR may progress, negatively impacting functional class, and survival [[#bb0015|[3]]]. Patients with severe TR after MV surgery and who are undergoing isolated tricuspid valve (TV) surgery, usually have high operative mortality, and no significant improvement in functional capacity [[#bb0020|[4]]] ;  [[#bb0025|[5]]]. On the contrary, many investigators have reported that even if there was an absence of any organic pathology, TR would not reliably resolve after the correction of the primary disorder [[#bb0030|[6]]]; [[#bb0035|[7]]] ;  [[#bb0040|[8]]].
26
27
Due to the common belief that TR will resolve itself once the primary LHD has been treated, cardiac surgeons have placed more attention on intra-operative concomitant TR treatment. In the United States, the total number of TV procedures more than doubled over the last 10-year period [[#bb0045|[9]]]. Although corrective surgery of severe functional TR (FTR) showed trends toward improved survival, either significant residual or recurrent TR has been reported in 15% to 40% of patients after different TV surgery [[#bb0050|[10]]]; [[#bb0055|[11]]] ;  [[#bb0060|[12]]]. Tricuspid valve replacement, which allows adequate surface area of co-aptation impossible, is associated with higher mortality [[#bb0065|[13]]] ;  [[#bb0070|[14]]]. Several studies have shown better long-term freedom from recurrent TV regurgitation and repeat operation in those who underwent TV repair [[#bb0075|[15]]]; [[#bb0080|[16]]]; [[#bb0085|[17]]]; [[#bb0090|[18]]]; [[#bb0095|[19]]] ;  [[#bb0100|[20]]]; however, data regarding the outcome of such an approach and the optimal surgical technique for TV repair is lacking [[#bb0030|[6]]] ;  [[#bb0105|[21]]].
28
29
The present article is based on our experience over the past five years with Chinese patients in our institution to advance the understanding of the effectiveness, the durability of different TV annuloplasty methods, and the risk factors involved with the surgical outcome.
30
31
==2. Methods==
32
33
We retrospectively analyzed the clinical reports of 399 consecutive patients (188 males, 211 females; age 46.7 years; range: 33–75 years) who underwent mitral surgery with concomitant tricuspid annuloplasty, from January 2006 to June 2011, in two Chinese single-centers (Changzheng Hospital and Changhai Hospital). Our exclusion criteria included those with: an organic disease of the TV, either congenital or infective tricuspid diseases, and either single or traumatic TR. Our institutional ethics committee approved the present study and all patients were given a written informed consent.
34
35
Each of the patients underwent pre-operative transthoracic echocardiography (TTE) within one month prior to surgery. The severity of FTR was evaluated using an apical four-chamber view, and graded from 0 to 4 + (0: none, 1 +: mild, 2 +: moderate, 3 +: moderate-to-severe, 4 +: severe).
36
37
All patients also underwent mitral surgery with cardiopulmonary bypass (CPB) established between both the venae cavae and the ascending aorta. Mild systemic hypothermia was reported in all cases. The myocardial protection used was identical for all patients, and consisted of an anterograde cold blood crystalloid cardioplegia with topical ice slush. We first corrected the mitral valve disease, and then proceeded, after aorta de-clamping, to perform a TV annuloplasty under the beating heart. There were three procedures used to apply the tricuspid annuloplasty: (1) De Vega group (DV Group): 242 patients under either traditional or modified De Vega surgery; (2) flexible band group (Flexible Group): annuloplasty with either the Duran ring (Medtronic) or Cosgrove band (Cosgrove–Edwards annuloplasty system; Edwards Lifesciences) in 98 patients; (3) and the rigid planner ring group (Rigid Group): annuloplasty with MC<sup>3</sup> ring (Edwards Lifesciences) in 59 patients. The type of tricuspid annuloplasty depended on a preference of the surgeon. The diameter of the annuloplasty was measured from the anteroseptal commissure to the antero-posterior commissure using a sterile supple ruler [[#bb0110|[22]]]. And the surgeon would choose the size of ring exactly according to the tricuspid diameter. We also performed a direct injection test, and utilized transesophageal echocardiography for intra-operative evaluation of TV function. Seven days after the valve repair, and at discharge, the temporal trend of the TR grades was assessed by TTE.
38
39
Individual patient contact after discharge was performed during either the outpatient process (69%), or with questionnaires (27%). Patients who did not respond were contacted by telephone (4%), and if no further information about the patients was available, we contacted their family physicians. The echocardiography data was evaluated based on TR grade and images were obtained at three months, six months, one year, and three years, postoperatively. The mean follow-up time was 3.3 years (range, 6 months–5.5 years). Seven patients were lost during follow-up. A total of 1467 TTE copies in 383 (96%) patients were analyzed during the follow-up.
40
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===2.1. Statistical analyses===
42
43
Results are expressed as either a number (percentages), mean (standard deviation), or as a median (range) when the distribution of variables was not normal. Continuous variables were compared using either the Student ''t'' test or the Mann–Whitney test and categorical outcomes by either ''χ''<sup>2</sup> or Fishers exact test. Univariate and multivariate Cox proportional hazard models were used to examine the risk factors for recurrent or persistent significant TR. Variables with a ''p'' value < 0.20 in univariate analyses were used for the multivariate models. Multivariate analyses involved a backward elimination technique and only variables with a ''p'' value < 0.10 were included in the final model. All reported ''p'' values are two-sided and a ''p'' value < 0.05 was considered statistically significant. Analyses were performed using the SPSS version 13.0 (SPSS Inc, Chicago, IL).
44
45
==3. Results==
46
47
===3.1. Baseline profiles===
48
49
The etiology of the mitral lesion was rheumatic heart disease in 251 (62.9%), regressive in 108 (27.1%), and infective endocarditis in 40 patients (10.0%). When classified by using the pre-operative New York Heart Association (NYHA) functional class, 255 patients (64%) were in both classes III and IV. By TTE, a TR grade of 1 + or 2 + was in 119 patients (29.8%) and a grade of 3 + or 4 + was in 280 patients (71.2%); mean right ventricular systolic pressure (mRVSP) was 44.2 ± 16.1 mm Hg and mean pulmonary arterial pressure (mPAP) was 35.2 ± 12.1 mm Hg. There were no significant differences in the pre-operative clinical details of patients in the three groups, such as age, gender, NYHA class, TTE results, or the percent of TR 3 + or 4 + grades ([[#t0005|Table 1]]).
50
51
<span id='t0005'></span>
52
53
{| class="wikitable" style="min-width: 60%;margin-left: auto; margin-right: auto;"
54
|+
55
56
Table 1.
57
58
Preoperative clinical details of 399 patients with functional tricuspid regurgitation.
59
60
|-
61
62
!  Variable
63
! De Vega group (n = 242, %)
64
! Flexible band group (n = 98, %)
65
! Rigid ring group (n = 59, %)
66
|-
67
68
| Age
69
|  46.2 ± 15.4
70
|  46.1 ± 14.7
71
|  47.7 ± 16.3
72
|-
73
74
|  Gender
75
| 
76
| 
77
| 
78
|-
79
80
|   Males
81
| 114 (47.1)
82
| 46 (46.9)
83
| 28 (47.5)
84
|-
85
86
|   Females
87
| 128 (52.9)
88
| 52 (53.1)
89
| 31 (52.5)
90
|-
91
92
|  NYHA[[#tf0005|<sup>⁎</sup>]]
93
| 
94
| 
95
| 
96
|-
97
98
|  Class II
99
| 90 (37.2)
100
| 35 (35.7)
101
| 20 (33.9)
102
|-
103
104
|  Class III
105
| 92 (38.0)
106
| 38 (38.8)
107
| 23 (40.0)
108
|-
109
110
|  Class IV
111
| 60 (24.8)
112
| 25 (25.5)
113
| 16 (27.1)
114
|-
115
116
| Atrial fibrillation
117
| 109 (45.0)
118
| 46 (46.9)
119
| 29 (49.2)
120
|-
121
122
|  Echocardiographic variables
123
| 
124
| 
125
| 
126
|-
127
128
|  Mitral stenosis
129
| 39 (16.1)
130
| 15 (15.3)
131
| 10 (16.9)
132
|-
133
134
|  Mitral incompetence
135
| 88 (36.4)
136
| 37 (37.8)
137
| 23 (40.0)
138
|-
139
140
|  Mitral mix lesions
141
| 115 (47.5)
142
| 46 (46.9)
143
| 26 (44.1)
144
|-
145
146
|   mPAP[[#tf0005|<sup>⁎</sup>]]
147
|  34.4 ± 12.3
148
|  35.7 ± 14.6
149
|  37.1 ± 16.1
150
|-
151
152
|   mRVSP[[#tf0005|<sup>⁎</sup>]]
153
|  43.9 ± 11.0
154
|  45.7 ± 12.9
155
|  45.1 ± 19.0
156
|-
157
158
|   LVEF[[#tf0005|<sup>⁎</sup>]]
159
|  55.1 ± 5.9
160
|  53.4 ± 4.1
161
|  56.2 ± 5.9
162
|-
163
164
|   TR[[#tf0005|<sup>⁎</sup>]] grade
165
| 
166
| 
167
| 
168
|-
169
170
|   1 +
171
| 3 (1.2)
172
| 3 (3.0)
173
| 2 (3.4)
174
|-
175
176
|   2 +
177
| 67 (27.7)
178
| 27 (27.6)
179
| 16 (27.1)
180
|-
181
182
|   3 +
183
| 89 (36.8)
184
| 35 (35.7)
185
| 21 (35.6)
186
|-
187
188
|   4 +
189
| 83 (34.3)
190
| 33 (33.7)
191
| 20 (33.9)
192
|}
193
194
The results of qualitative variables are expressed in absolute values (percentages) and the results of continuous variables are expressed as mean (SD).
195
196
⁎. NYHA = New York Heart Association; mPAP = mean pulmonary arterial pressure; mRVSP = mean right ventricular systolic pressure; LVEF = left ventricular ejection fraction; TR = tricuspid regurgitation.
197
198
===3.2. Clinical outcomes===
199
200
During surgery, there were no significant differences found within groups regarding CPB, aorta clamping time, and concomitant surgery. Due to the size of the annuloplasty ring, a 28# flexible band and MC<sup>3</sup> ring were more commonly used. There was more 30# rings utilized in the Flexible Group, and a greater number of 26# bands in the Rigid Group.
201
202
The operative mortality was 2.3% (9/399). The main cause of death was multiple organ dysfunction syndrome in five patients. Two patients died of low output syndrome and the other two died of severe infection. The cause of death was attributed to pre-operative poor condition ([[#t0010|Table 2]]).
203
204
<span id='t0010'></span>
205
206
{| class="wikitable" style="min-width: 60%;margin-left: auto; margin-right: auto;"
207
|+
208
209
Table 2.
210
211
Intraoperative and postoperative information of 399 patients undergoing concomitant tricuspid annuloplasty.
212
213
|-
214
215
!  Variable
216
! De Vega group (n = 242, %)
217
! Flexible band group (n = 98, %)
218
! Rigid ring group (n = 59, %)
219
|-
220
221
| colspan="4" | ''Intraoperative outcome''
222
|-
223
224
| Mitral surgery
225
| 
226
| 
227
| 
228
|-
229
230
|  Mitral replacement
231
| 189 (78.1)
232
| 72 (73.5)
233
| 45 (76.3)
234
|-
235
236
|  Mitral repair
237
| 50 (20.1)
238
| 25 (25.5)
239
| 13 (22.0)
240
|-
241
242
| Size of TV[[#tf0010|<sup>⁎</sup>]] prosthetic ring
243
| 
244
| 
245
| 
246
|-
247
248
|  26
249
| /
250
| 4 (4.1)
251
| 6 (10.2)
252
|-
253
254
|  28
255
| /
256
| 60 (61.2)
257
| 39 (66.1)
258
|-
259
260
|  30
261
| /
262
| 32 (32.3)
263
| 14 (23.7)
264
|-
265
266
|  32
267
| /
268
| 2 (2.0)
269
| 0 (0.00)
270
|-
271
272
|  Concomitant surgery
273
| 
274
| 
275
| 
276
|-
277
278
|   CABG[[#tf0010|<sup>⁎</sup>]]
279
| 3 (1.2)
280
| 1 (1.0)
281
| 1 (1.7)
282
|-
283
284
|  CPB[[#tf0010|<sup>⁎</sup>]] duration, minutes
285
|  75.0 ± 10.0
286
|  80.2 ± 10.7
287
|  81.4 ± 9.1
288
|-
289
290
| Aorta clamping time, minutes
291
|  42.1 ± 9.3
292
|  40.9 ± 6.5
293
|  39.2 ± 7.3
294
|-
295
296
|  Mechanical ventilation time, hours
297
|  9.1 ± 1.1
298
|  8.3 ± 1.6
299
|  8.6 ± 1.5
300
|-
301
302
|  ICU[[#tf0010|<sup>⁎</sup>]] duration, days
303
|  2.4 ± 0.2
304
|  2.5 ± 0.4
305
|  2.4 ± 0.3
306
|-
307
308
| Hospital stay, days
309
|  16.1 ± 1.1
310
|  15.5 ± 1.4
311
|  15.0 ± 1.1
312
|-
313
314
| colspan="4" | 
315
|-
316
317
| colspan="4" | ''Postoperative outcome''
318
|-
319
320
| Early death
321
| 5 (2.1)
322
| 2 (2.1)
323
| 2 (3.4)
324
|-
325
326
|  Low output syndrome
327
| 2
328
| 0
329
| 0
330
|-
331
332
|   MODS[[#tf0010|<sup>⁎</sup>]]
333
| 2
334
| 1
335
| 2
336
|-
337
338
|  Serve infection
339
| 1
340
| 1
341
| 0
342
|-
343
344
|  Installation of permanent pacemaker
345
| 8 (3.3)
346
| 3 (3.1)
347
| 1 (1.7)
348
|-
349
350
|  Reoperation due to TR[[#tf0010|<sup>⁎</sup>]] in 5 years
351
| 5
352
| 2
353
| 0
354
|-
355
356
|  Suture avulsion
357
| 4
358
| 1
359
| /
360
|-
361
362
|  Pacing wires
363
| 1
364
| 1
365
| /
366
|}
367
368
The results of qualitative variables are expressed in absolute values (percentages) and the results of continuous variables are expressed as mean (SD).
369
370
⁎. TV = tricuspid valve; CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; ICU = intensive care unit; MODS = multiple organ dysfunction syndrome; TR = tricuspid regurgitation.
371
372
===3.3. Efficiency of a different annuloplasty in treating FTR===
373
374
After surgery, the TR grade and mPAP of all patients significantly decreased ([[#t0015|Table 3]]). According to the TTE results, at three and six months, and one and three years during the follow-up, 4.7% (18/383), 8.6% (33/382), 11.9% (45/378) and 13.7% (51/373) patients were found to have recurrent TR, respectively. During follow-up, the recurrent rate of the TR 3 + grade was always higher in the DV Group than the Flexible and Rigid Groups. At three years, there were 18.2% of patient graded as TR 3 + in the DV Group, which was much higher than those in the Flexible (8.4%, ''p'' < 0.05) or Rigid Groups (5.2%, ''p'' < 0.05). The recurrent rates were significantly lower in the Rigid Group than in the Flexible Group at six months, one year, and three years ([[#f0005|Fig. 1]]).
375
376
<span id='t0015'></span>
377
378
{| class="wikitable" style="min-width: 60%;margin-left: auto; margin-right: auto;"
379
|+
380
381
Table 3.
382
383
Influence of different annuloplasty on TR grade, mPAP and mRVSP.
384
385
|-
386
387
!  Variable
388
! De Vega group (n = 242, %)
389
! Flexible band group (n = 98, %)
390
! Rigid ring group (n = 59, %)
391
|-
392
393
|  TR[[#tf0015|<sup>a</sup>]] grade
394
| 
395
| 
396
| 
397
|-
398
399
|   Preop-[[#tf0015|<sup>a</sup>]]
400
|  2.84 ± 1.1
401
|  2.70 ± 0.9
402
|  2.61 ± 0.7
403
|-
404
405
|   Postop-[[#tf0015|<sup>a</sup>]]
406
|  0.71 ± 0.6[[#tf0030|<sup>b</sup>]]
407
|  0.32 ± 0.1<sup>[[#tf0030|b]] ;  [[#tf0020|c]]</sup>
408
|  0.20 ± 0.1<sup>[[#tf0030|b]] ;  [[#tf0020|c]]</sup>
409
|-
410
411
|  mPAP[[#tf0015|<sup>a</sup>]] (mm Hg)
412
| 
413
| 
414
| 
415
|-
416
417
|   Preop-
418
|  34.4 ± 10.3
419
|  35.7 ± 11.6
420
|  37.1 ± 12.1
421
|-
422
423
|   Postop-
424
|  23.1 ± 9.1[[#tf0030|<sup>b</sup>]]
425
|  25.2 ± 9.4[[#tf0030|<sup>b</sup>]]
426
|  24.9 ± 10.6[[#tf0030|<sup>b</sup>]]
427
|-
428
429
|  mRVSP[[#tf0015|<sup>a</sup>]] (mm Hg)
430
| 
431
| 
432
| 
433
|-
434
435
|   Preop-
436
|  43.9 ± 11.0
437
|  45.7 ± 12.9
438
|  45.1 ± 19.0
439
|-
440
441
|   Postop-
442
|  35.4 ± 13.8
443
|  36.3 ± 11.4
444
|  35.9 ± 12.7
445
|}
446
447
a. TR = tricuspid regurgitation; Preop- = preoperative; Postop- = postoperative; mPAP = mean pulmonary arterial pressure; mRVSP = mean right ventricular systolic pressure.
448
449
b. Comparing with preoperative value: ''p'' < 0.01.
450
451
c. Comparing with De Vega Group: ''p'' < 0.05.
452
453
<span id='f0005'></span>
454
455
{| style="text-align: center; border: 1px solid #BBB; margin: 1em auto; max-width: 100%;" 
456
|-
457
|
458
459
460
[[Image:draft_Content_440350521-1-s2.0-S2352906714000803-gr1.jpg|center|505px|The recurrent rates of tricuspid regurgitation after three different ...]]
461
462
463
|-
464
| <span style="text-align: center; font-size: 75%;">
465
466
Fig. 1.
467
468
The recurrent rates of tricuspid regurgitation after three different annuloplasty.
469
470
*FTR = functional tricuspid regurgitation; Postop- = postoperative.
471
472
</span>
473
|}
474
475
===3.4. Risk factors for recurrence TR after tricuspid annuloplasty===
476
477
Seven patients had a repeat operation to alleviate the recurrent TR. Four patients underwent TV replacement; in three patients the repair was successful. One patient died after the repeat operation.
478
479
Multivariate analysis revealed that atrial fibrillation, either a preoperative 3 + or 4 + grade of TR, LAD ≥ 60 mm, LVEF < 40%, De Vega annuloplasty, and a postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR upon tricuspid repair ([[#t0020|Table 4]]).
480
481
<span id='t0020'></span>
482
483
{| class="wikitable" style="min-width: 60%;margin-left: auto; margin-right: auto;"
484
|+
485
486
Table 4.
487
488
Risk factors of recurrent tricuspid regurgitation after tricuspid annuloplasty.
489
490
|-
491
492
! rowspan="2" | 
493
! colspan="2" |  Recurrent TR[[#tf0025|<sup>⁎</sup>]] grade 
494
! rowspan="2" | ''p'' value
495
! colspan="3" |  Multivariate analysis 
496
|-
497
498
!  TR ≤ 2 + (n = 322)
499
!  TR ≥ 3 + (n = 51)
500
!  RR[[#tf0025|<sup>⁎</sup>]]
501
! 95% CI
502
! ''p'' value
503
|-
504
505
| Age (year)
506
|  45.4 ± 14.7
507
|  47.7 ± 16.4
508
|  0.68
509
| 
510
| 
511
| 
512
|-
513
514
|  Female
515
| 175 (54.3%)
516
| 26 (50.9%)
517
|  0.54
518
| 
519
| 
520
| 
521
|-
522
523
| Atrial fibrillation
524
| 119 (27.0%)
525
| 49 (96.1%)
526
|  0.0001
527
| 9.4
528
|  2.3–65.0
529
|  0.001
530
|-
531
532
|  NYHA[[#tf0025|<sup>⁎</sup>]] class IV
533
| 74 (23.1%)
534
| 15 (29.5%)
535
|  0.43
536
| 
537
| 
538
| 
539
|-
540
541
|  Rheumatic heart disease
542
| 221 (68.6%)
543
| 30 (58.8%)
544
|  0.043
545
| 
546
| 
547
| 
548
|-
549
550
| Mitral stenosis
551
| 49 (15.2%)
552
| 11 (21.6%)
553
|  0.31
554
| 
555
| 
556
| 
557
|-
558
559
| Mitral incompetence
560
| 125 (38.8%)
561
| 15 (29.4%)
562
|  0.16
563
| 
564
| 
565
| 
566
|-
567
568
| Mitral mix lesions
569
| 148 (54.0%)
570
| 25 (49.0%)
571
|  0.09
572
| 
573
| 
574
| 
575
|-
576
577
|  LVEF[[#tf0025|<sup>⁎</sup>]]< 40%
578
| 89 (27.7%)
579
| 31 (60.1%)
580
|  0.001
581
| 3.4
582
|  1.6–12.1
583
|  0.04
584
|-
585
586
| Left atrial diameter ≥ 60 mm
587
| 87 (27.0%)
588
| 36 (70.6%)
589
|  0.01
590
| 2.7
591
|  1.2–7.9
592
|  0.03
593
|-
594
595
|  mPAP[[#tf0025|<sup>⁎</sup>]]≥ 50 mm Hg
596
| 94 (29.2%)
597
| 18 (35.3%)
598
|  0.05
599
| 
600
| 
601
| 
602
|-
603
604
|  mRVSP[[#tf0025|<sup>⁎</sup>]]≥ 60 mm Hg
605
| 97 (30.1%)
606
| 18 (35.3%)
607
|  0.06
608
| 
609
| 
610
| 
611
|-
612
613
|  Preoperative TR grade ≥ 3 +
614
| 207 (64.3%)
615
| 47 (92.1%)
616
|  0.001
617
| 3.6
618
|  1.7–8.7
619
|  0.002
620
|-
621
622
|  Tricuspid annulus diameter ≥ 45 mm
623
| 140 (43.5%)
624
| 28 (54.9%)
625
|  0.04
626
| 
627
| 
628
| 
629
|-
630
631
| Mitral repair
632
| 79 (24.5%)
633
| 9 (17.6%)
634
|  0.07
635
| 
636
| 
637
| 
638
|-
639
640
| De Vega annuloplasty
641
| 202 (62.7%)
642
| 40 (78.4%)
643
|  0.001
644
| 7.2
645
|  2.7–15.4
646
|  0.002
647
|-
648
649
|  Tricuspid prosthetic ring size ≤ 28 mm
650
| 102 (29.3%)
651
| 7 (13.7%)
652
|  0.32
653
| 
654
| 
655
| 
656
|-
657
658
|  Installation of permanent pacemaker
659
| 1 (0.3%)
660
| 11 (21.5%)
661
|  0.02
662
| 2.5
663
|  1.1–8.7
664
|  0.015
665
|}
666
667
⁎. TR = tricuspid regurgitation; RR = risk ratio; NYHA = New York Heart Association; LVEF = left ventricular ejection fraction; mPAP = mean pulmonary arterial pressure; mRVSP = mean right ventricular systolic pressure.
668
669
==4. Discussion==
670
671
Our results showed that though rigid ring annuloplasty did not significantly decrease the incidence of adverse clinical outcomes, it was effective in improving the post-operative TV function in patients with FTR undergoing mitral surgery. Either the traditional or modified De Vega annuloplasty did not show a beneficial effect on long-term TV function. Furthermore, a preoperative 3 + or 4 + grade of TR, AF, LAD ≥ 60 mm, LVEF < 40%, De Vega annuloplasty, and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR upon tricuspid repair.
672
673
The most common etiologies of FTR are right ventricular (RV) dilation and dysfunction from LHD. As in cases of MV disease [[#bb0115|[23]]], mild FTR was reported in up to 74–86% of patients with left heart valve disease [[#bb0060|[12]]]. In our series, 62.9% patients had rheumatic MV pathology, which was similar to previous series [[#bb0120|[24]]]. MV disease leads to mitral stenosis, either regurgitation or mix lesion, causing an increase in left atrial pressure and, in some severe cases, secondary pulmonary hypertension. Increased afterload may lead to RV dysfunction and cardiomyopathy remodeling, resulting in either tricuspid annulus dilatation or tethering of the TV leaflets, leading to FTR [[#bb0005|[1]]]. By increasing left atrial size and pressure, MV disease might also cause AF, which gradually causes right atrial enlargement and leads to further tricuspid annular dilation. AF was recognized as an important risk factor for the development of TR in patients with MV disease as well as for either the occurrence or progression of TR after MV surgery [[#bb0005|[1]]]. Our results show that AF is a primary risk factor of recurrent moderate to severe TR. Furthermore, patients who had a concomitant successful Maze procedure during their MV surgery were reported to have significantly less TR at follow-up; however, patients with AF in our series did not routinely undergo Maze surgery.
674
675
FTR is primarily treated with a valve reconstruction that carries a much lower operative risk than valve replacement [[#bb0075|[15]]] ;  [[#bb0125|[25]]]; however, there is still a heated debate regarding the superior method of repair (either suture based or a prosthetic ring annuloplasty). McCarthy [[#bb0130|[26]]] reported that both flexible bands and rigid planner rings had much less recurrent TR than the De Vega procedures. During our follow-up, it showed the similar results: at three years during follow-up, there were 18.2% of patient graded as TR 3 + in the DV Group, which was much higher than those in the Flexible (8.4%) or Rigid Groups (5.2%). Filsoufi [[#bb0135|[27]]] and De Bonis [[#bb0040|[8]]] found excellent reductions in TR severity early and mid-term after surgery with the MC<sup>3</sup> ring. Ghoreishi [[#bb0140|[28]]] showed that the rigid three-dimensional ring could be the most reliable and durable treatment for FTR. This ring annuloplasty provides an early and sustained reduction of TR secondary to LVD, which has been reported by Navia [[#bb0145|[29]]]. In our series, the recurrent rates were significantly lower in the Rigid Group than in the Flexible Group postoperatively. However, though the MC<sup>3</sup> ring was found to be superior to conventional techniques, about 14% of patients had TR graded greater than moderate one year after surgery: post-operative TR severity was associated with preoperative TR severity and extensive leaflet tethering [[#bb0150|[30]]]. And Pfannmuller [[#bb0020|[4]]] found that though both rigid and flexible systems could provide acceptable results, but that the use of a rigid ring may significantly increase the risk of early annular dehiscence. These results revealed that all of the annuloplasty methods did not permanently eliminate secondary TR. Thus, more studies are needed to explore the superior method of TV repair.
676
677
The incidence of a post-operative pacemaker implantation was reported from 3% to 6% after valve interventions [[#bb0045|[9]]]. A few studies have found that the need of pacemakers after a TV operation is higher than after other valve interventions [[#bb0010|[2]]]; [[#bb0035|[7]]] ;  [[#bb0155|[31]]]; however, the need and clinical implications of pacemaker implantation after a TV operation are less documented. In our series, the rate of pacemaker implantation was 3% (much lower than other TV operation studies [[#bb0155|[31]]] ;  [[#bb0160|[32]]]) and permanent pacemaker implantation was found to be an independent risk factor of recurrent TR during follow-up. One study showed that the survival of patients who needed a pacemaker after a TV operation was outstandingly higher than of those who did not [[#bb0155|[31]]]. More data about the general results and the need for a pacemaker after the TV operations are essential for further development of useful methods.
678
679
Our study is unique and summarizes the Chinese experience of treating FTR concomitant with mitral surgery over the past five years; however, we realize the potential limitations of our study. First, this is a retrospective cohort study containing different surgical techniques that were used in part because of the dissatisfaction with effectiveness, and surgeon preference. Secondly, the surgical preference may change in favor of rigid TV annuloplasty over the passage of time. This may cause some selection bias. Furthermore, a longer follow-up will be required to confirm our results.
680
681
==5. Conclusions==
682
683
Neither traditional nor modified De Vega annuloplasty did not show a beneficial effect on long-term TV function. Compared with a flexible system, MC<sup>3</sup> rigid ring annuloplasty may provide better effectiveness in improving postoperative TV function in patients with FTR undergoing mitral surgery. Atrial fibrillation, a large left atrium, low LVEF and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.
684
685
==Conflict of interest==
686
687
None.
688
689
==Acknowledgments==
690
691
None.
692
693
==References==
694
695
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760

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