Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation.

Background: Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.
Objectives: The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.
Methods: Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.
Results: Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).
Conclusions: After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
Competing Interests: Funding Support and Author Disclosures The Cardiothoracic Surgical Trials Network (CTSN) is supported by a cooperative agreement (U01 HL088942) funded by the National Heart, Lung, and Blood Institute and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health, and the Canadian Institutes for Health Research. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, the National Institutes of Health, or the U.S. Department of Health and Human Services. Dr. Ailawadi has received honoraria (modest) from Medtronic, Edwards, Abbott, Admedus, and Gore. Dr. Thourani has served on the Advisory Board (modest) for Gore Vascular; and has received research grants (modest) from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Jenavalve. Dr. Mack has received honoraria (modest) from Gore; and has received research grants (modest) from Edwards Lifesciences, Medtronic, and Abbott. Dr. Gillinov has served as a consultant (significant) for Medtronic, AtriCure, Edwards Lifesciences, Abbott, CryoLife, and ClearFlow; and has an ownership interest (significant) in ClearFlow. Dr. Giustino has received honoraria (modest) from Bristol Myers Squibb. Dr. O’Gara has been a member of the Executive Committee for the Apollo Trial (TMVR) (modest) for Medtronic; has served as a member of the Executive Committee for the Early TAVR trial (modest) for Edwards Lifesciences; and has served as a member of the Scientific Advisory Board (modest) for MedTrace. Dr. Gammie has served as a consultant (modest) for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)