Concomitant Tricuspid Valve Repair During Mitral Valve Surgery: Indication and Surgical Outcome

Concomitant Tricuspid Valve Repair During Mitral Valve Surgery: Indication and Surgical Outcome Osamah Obaid Ibrahim  Department of Surgery, College of Medicine, University of Thi-Qar, Thi-Qar, Iraq Abstract Background: Tricuspid valve repair has been recently advocated in patients undergoing mitral valve surgery who have mild to moderate secondary tricuspid regurgitation. The study aimed to find out how the concomitant performance of tricuspid valve repair (TVR) affects outcomes of patients undergoing mitral valve surgery (MVS). Methodology: Retrospective cross sectional analytical study that was carried out from 15 June to 31 December 2020 in Ibn Al-Bitar hospital for cardiac surgery and Iraqi heart center of 24 patients that were referred for MVR. and TV. repair from 6 up to 3 years were they assessed preoperatively, intraoperative and postoperative. Data collected from patient's files in data were retrieved from the hospital data collecting .The follow up after phoning patient and contact with them by what's up application for sending their data and echocardiogram reports. Results: The total sample was 24 patients. The mean age was 59.7+/- 6.4 year ,Female forming 58.3% and male was 43.7%.The new York Heart Association (NYHA) on collected patients showed class ΙΙΙ in 75% patients and class Ιν in 25% in preoperative period improved reversely to became 75% in class Ι and 25% in class ΙΙ after 6 months while after 1 year the patients reclassified to [25%, 20.8%,4/1% and 50% with class Ι,ΙΙ,ΙΙΙ, and asymptomatic respectively ] and in to [45.8%, 16.6%, and 37.5% with class Ι,ΙΙ and asymptomatic respectively after 3 years]. Preoperative echocardiographic assessment showed that the mean of annular size was 31.5+/-2.9 mm.( ranging 27mm-38mm).The average length of stay in the intensive care unit (ICU) 2.7+/- 2.1 days, 2(8.3%) patient need for pacemaker, acute renal failure developed in 1 patient and there were no bleeding, madiastinitis, wound infection, thromboembolisation, endocarditis and death. The study showed the postoperative progression of the TR. was 8(33.3%) with moderate TR. and 16(66.7%) with sever TR. improved in 6 months in to [6(25%), 12(50%),and 6(25%) with no TR. ,mild TR. and moderate TR. respectively ] and in to [14(58.3%),8(33.3%),2(8.3%) with no TR, mild and moderate TR. respectively] after 1 year and [4(16.6%),16(66.7%) with no TR. and mild TR. and 2 (8.3%) with moderate and sever TR.]after 3 years. Conclusion: All patients with moderate – sever tricuspid are candidate for repair. The short term outcome show improvement in functional state and in valve regurge but in mid – long term outcome there is gradual decrease in it. Introduction Tricuspid regurgitation (TR) is a frequent echocardiographic finding, being present in up to 80-90 per cent of the general population, but is most often mild or functional as opposed to organic; relevant progression is dependent on age and gender [1]. Isolated TR surgery is uncommon and only a few of the operations are conducted in the presence of other heart surgeries although they produce significant symptoms [2]. There are however indications that isolated tricuspid valve surgery can attain satisfactory operative mortality when done prior to advanced heart More Information How to cite this article: Ibrahim OO. Concomitant Tricuspid Valve Repair During Mitral Valve Surgery: Indication and Surgical Outcome. Eur J Med Health Res, 2025;3(5):270-6. DOI: 10.59324/ejmhr.2025.3(5).36 Keywords: Tricuspid regurgitation (TR), Mitral Valve Surgery, Indication, Surgical Outcome. This work is licensed under a Creative Commons Attribution 4.0 International License. The license permits unrestricted use, distribution, and reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes. EUR J MED HEALTH RES Volume 3 | Number 5 | 2025 271 failure or severe right ventricular (RV) dysfunction [3]. The AHA/ACC defines TR progression into four stages (A-D) [4], and the latest guidelines suggest isolated tricuspid valve surgery of symptomatic severe primary TR prior to major RV dysfunction (Class IIa), or a conservative treatment of isolated patients by serial RV evaluation (Class IIb) [5]. Functional tricuspid regurgitation (FTR) is an acquired nonorganic disease that occurs as a secondary result of left-sided heart disease or pulmonary hypertension [6], initially described in the 1950s, and initially believed to resolve following correction of left-sided lesions [7]; but residual or recurrent TR is likely to persist when the tricuspid valve is not repaired during left-sided surgery, which contributes to subsequent morbidity and mortality [8,9]. The largest cardiac valve is the tricuspid valve (TV), which has three leaflets (anterior, posterior, septal), chordae tendineae, papillary muscles, and the fibrous annulus and makes the operation close to the atrioventricular node and the right coronary artery challenging to operate on [10,11]. Most forms of repair use replacement only when the tethering is severe, and repair includes only ring or suture annuloplasty (De Vega), with rigid rings showing better long-term results [12,13]; adjunctive repairs such as anterior leaflet augmentation, clover, or double-orifice technique can also be used. In the case of primary TR, repair can be done by leaflet resection, chordal replacement, papillary muscle plasty, or commissurotomy based on pathology14. Replacement of the valves is done only in case of severely damaged or non-repairable ones as in the case of endocarditis, carcinoid, or radiationinduced condition, but reoperations are very risky [14,15]. The research will compare preoperative, intraoperative, and postoperative evaluation and care of tricuspid repair done during the operation of mitral valves replacement and also assess the short and midterm outcome of these work . Methodology The period of conducting this retrospective crosssectional analytical study was between 15 June and 31 December 2020 at both Ibn Al-Bitar Hospital of heart surgery and the heart center of Iraq. It comprised 24 patients who had their mitral valve (MVR) replaced and had their tricuspid valve (TV) repaired and the followup was between 3 to 6 years. The population of the study was patients with mitral valve disease, presented mostly as mitral regurgitation, and secondary (functional) tricuspid regurgitation (TR). Patients with mitral stenosis, organic TR, those who needed further valve operations, and those who had mitral valve repair were excluded. Echocardiographic reports on preoperative values were also obtained such as the tricuspid annular size, leaflet coaptation, and jet values. The intraoperative evaluation involved assessment of the TV, right ventricle, annulus and leaflets whereas the postoperative assessment was based on the residual severity of TR, mortality and postoperative complications such as the need of pacemaker. Other clinical information (age, sex, comorbidities and echocardiographic results) was gathered using hospital records, surgical notes, and discharge summaries. Direct communication with patients in the form of a phone interview and via WhatsApp, with the updated echocardiography report, was taken into account as follow-up data. Surgical Procedure Every patient was subjected to median sternotomy and longitudinal right sided left atriotomy. Mitral valve replacement was done with a bileaflet mechanical, and then left atria was stitched. As soon as the aortic crossclamp had been lifted, the right atria was incised obliquely to examine the tricuspid valve on the beating heart. With or without valve and annular condition, tricuspid annuloplasty followed either with the De Vega suture or ring annuloplasty. Intraoperative tests were valve competence tests that were performed by administering a saline (water) test to determine any remaining regurgitation before the patient stopped having cardiopulmonary bypass. Statistical Analysis The collected data were compared, verified, and analyzed with the help of the Statistical Package of the Social Sciences (SPSS). Student t-test was applied in testing the hypothesis of the quantitative variables, measured using arithmetic mean and standard deviation. Qualitative data in the form of proportions were performed by the chi-square (kh2) test. A P-value of above 0.05 was regarded as nonsignificant, above 0.05 significant and above 0.01 highly significant. Results The total sample was 24 patients. The age of patients ranging from 48-69 years and the mean age was 59.7+/- 6.4 year, Female forming 58.3% and male was 43.7%. Figure 1: The Gender Distribution of the Patients (n=24) 43.7 58.3 male female EUR J MED HEALTH RES Volume 3 | Number 5 | 2025 272 Diabetes form more than one half of the cases (54.2%, 13patients) as in figure 2. Figure 2: Association with the Comorbid Illnesses The New York Heart Association (NYHA) functional status on collected patients on admission showed that (75%, 18) 0f them were class ΙΙΙ and (25%, 6 patients) were class Ιν as shown in figure 3 with 5 of the patients had fluid overload (2,8.3% had ascites) and (3,12.5% had pleural effusion). Figure 3: Functional Class Distribution of the Patients (n=24) All patients underwent preoperative echocardiographic assessment and showed that the mean of annular size was 31.5+/-2.9 mm. ranging from 27mm-38mm as in figure (4), but the severity of TR. Was varied from moderate to severe one. Figure 4: Preoperative Echocardi Ographic Assessment (Annular Size) n=24 Table 1: Preoperative Echocardiographic Assessment (Severity of TR.) n=24 percent frequency TR. Severity no no mild 33.3 8 moderate 66.7 16 sever 100 24 total Table 2: Demographic and Basic Echocardiographic Data Preoperatively n. 24 Age 59.6+/-6.4 year 54.2 16.716.7 20.8 13 445 0 10 20 30 40 50 60 DM HTN IHD AF 1 2 EUR J MED HEALTH RES Volume 3 | Number 5 | 2025 273 Sex Female 13 (58.3%) Male 11 (41.7%) NYHA class class ΙΙΙ 18 (75%) class Ιν 6 (25%) DM. 13 (54.2%) HTN. 4 (16.7%) IHD. 4 (16.7%) AF 5 (20.8%) Echo. Finding: -annular size - Severity of TR. 31.5+/-2.9 mm from (27-38mm). -moderate 8(33.3%) -sever 16(66.7%) The average length of stay in the intensive care unit (ICU) 2.7+/- 2.1 days only 2(8.3%) patient need for pacemaker due to development of bradycardia, acute renal failure developed in one 1 patient and there were no significant post-operative bleeding, madiastinitis, wound infection, thromboembolisation, endocarditis and death. Table 3: Postoperative Complications Inotrope needed during Icu admission 2 Post-operative renal failure 1 Pleural effusion required drainage 1 Temporary pacing 2 The patients was followed after discharge from hospital by dating for comparison the symptoms and severity of valve by echocardiogram through 6months, 1year and 3 years showed in table (4-4). Table 4: Comparison of the NYHA Class and Severity of TR by Echocardiogaphy during the 6 Monthes,1 Year and 3 Years Follow Up (n=24) 3YEARS 1YEAR 6MONS Preop. severity 3YEARS 1YEAR 6MONS Preop. NYHA 4 (16.6%) 14 (58.3%) 6 (25%) no TR 11 (45.8%) 6 (25%) 18 (75%) 1 16 (66.7%) 8 (33.3%) 12 (50%) mild 4 (16.6%) 5 (20.8%) 6 (25%) 2 2 (8.3%) 2 (8.3%) 6 (25%) 8 (33.3%) mod 1 (4.1%) 18 (75%) 3 2 (8.3%) 16 (66.7%) sever 6 (25%) 4 9 (37.5%) 12 (50%) N0 symptoms. Discussion The study was collected retrospectively as analytical cross sectional study in order to assess the patients that underwent mitral valve replacement preoperative with repair of TV. Intraoperatively and follow up them in postoperative period from (6months -3 years). The study showed the mean age was 59.7+/- 6.4, male forming 43.7% (figure 1) similar to that age collected in Bettina Pfannmüller et al and in other studies with male percent forming 41.7% due to increase prevalence of mitral valve disease in female [16]. Patients with FTR and AF (5 patients, 20.8%) as in figure 2 had a larger TV annular area with weaker annular contraction (both P<0.001) but similar leaflet coaptation and functional status (NYHA ΙΙΙ) compared with patients with FTR and sinus rhythm the same opinion of Hiroto utsonumiya et al, that results suggest that in patients with TR and AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation [17]. Figure 2 also discussed the other chronic disease like diabetes and hypertension in functional TR. and EUR J MED HEALTH RES Volume 3 | Number 5 | 2025 274 showed (54.2%, 16.7% respectively) similar to many studies were performed on the effect of hypertension on the right ventricular (RV) systolic and diastolic functions as RV function plays a pivotal role in the course of heart failure, atrial fibrillation, ventricular arrhythmias, and sudden death. Albeit, only limited information is present on RV function in diabetic patients. Diabetic patients suffer from multiple causes of death; the most common is cardiovascular disease. Consistent with Inas Ibrahim Eweda study [18] which showed that the combined effect of both, DM and HTN on RV function is more evident than the effect of one of them alone, Inconsistent with our study that showed the diabetes was more prevalent. Figure 3, 4 considered NYHA classification (18, 75%) with class ΙΙΙ (12 patients, 50%) was had severed TR. and the resting 25% with class Ιν (4 of them 16.7%) with sever TR.as Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation [19]. The annular size (p=0.5) mean 31.5+/- 2.9 mm [33.3% from 31-33mm, 20.8% from 29-38mm, 41.7 from 27-35%] consist with Kunio Kusajima et al, findings [19,20]. Table 3 and 4 showed our following to the patients from post-operative period, 6monthes, 1year and 3 years including average length of stay at ICU 2.7+/-2.1 days which was closely comparable to another study in which it (replacement, 4 days; repair, 3 days; p = 0.45) [22], albeit, some studies showed a long time in ICU period in mitral valve replacement especially with TV. Repair [20]. During their staying in intensive care unit (28.3%) need inotrope , (1 - 4.2%) developed acute kidney injury treated conservatively, (1 patient, 4.2%) that he was already had pleural effusion preoperatively increased in volume post operatively needed drainage,(2 patients, 8.3%) required temporary pacing due to development of bradycardia results agreed with the results of Ayse Cetinkaya, Natalia Ganchewa et al, that had 8.8% need pacemaker during concomitant TV. Repair [20,27]. These study not show any complications of postoperative period (include operation complication) such as bleeding ,wound infection, thromboembolism, madiastinitis, endocarditis and 100% survival rate even in extended follow up (6monthes -3years) consistent with studies as in wang kin wong et al, that said that TV repair demonstrated significantly lower risks of allcause mortality [23] .As Tie yuan Zhu et al, who suggest that there is good evidence to support that tricuspid annuloplasty is a low-risk procedure and concomitant TV repair does not significantly increase the perioperative mortality and morbidity when correcting left-sided valve disease [26,28]. Figure 5: Progression of Symptoms Assessed by Functional State (NYHA CLASS) during Follow Up Period (6months-3 years) after Mitral Valve Replacement with Concomitant Tricuspid Repair The study in order to assess the results of the surgery at the long term and in mentioned period tried to focus on the functional state by recorded symptomatic improvement and echocardiographic assessment of the EUR J MED HEALTH RES Volume 3 | Number 5 | 2025 275 severity of TR. as in table 4 showed NYHA class ΙΙΙ in 75% patients and class Ιν in 25% in preoperative period improved reversely to became 75% in class Ι and 25% in class ΙΙ after 6 months while after 1 year the patients reclassified to [25%, 20.8%,4/1% and 50% with class Ι,ΙΙ,ΙΙΙ, and asymptomatic respectively ] and in to [45.8%, 16.6%, and 37.5% with class Ι,ΙΙ and asymptomatic respectively after 3 years]. These study prove what discussed in other studies about TV repair is associated with better shortand long-term outcomes in concomitant MVS [23]. In table 4 also showed the postoperative progression of the TR. through the study period of follow up and compare it with the preoperative period in which 8(33.3%) with moderate TR. and 16(66.7%) with sever TR. improved in 6 months in to [6(25%), 12(50%),and 6(25%) with no TR. ,mild TR. and moderate TR. respectively ] and in to [14(58.3%),8(33.3%),2(8.3%) with no TR, mild and moderate TR. respectively] after 1 year and [4(16.6%),16(66.7%) with no TR. and mild TR. and 2 (8.3%) with moderate and sever TR. after 3years] by these data we can see that the TR. improve during the short term follow up after the surgery but start to progress at mid – long term period consist with Kunio Kosajima et al [24]. For patients undergoing mitral valve surgery, late functional TR progression is frequently observed in the follow-up. The development of moderate-to-severe TR was associated with a poor prognosis [25,29]. Conclusion Mitral valve surgery is safe procedure, technically feasible and successfully performed for different valve pathologies so to improve in outcome and decrease mortality it concomitantly performed with tricuspid repair. all patient with moderate – sever tricuspid are candidate for repair when referred to cardiovascular surgery. The short-term outcome show improvement in functional state and in degree of regurgitation but in mid – long term follow up there is gradual worsening in valve regurge. Patients with Atrial fibrillation who plan for mitral valve replacement and tricuspid repair that expected to have large annular size and weak leaflet can be treated without replacement rather than repair. References [1] Sudhakar BGK. Evaluation and Management of Primary Tricuspid Regurgitation. Indian J Clin Cardiol. 2020. doi:10.1177/2632463620954091 [2] Topilsky Y. 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