Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure?

Objectives: Techniques employed today concomitantly with left-sided heart valve surgery address secondary tricuspid valve regurgitation at 3 anatomic levels-annulus, commissure, and leaflet-although success of these alone or in combination in eliminating tricuspid regurgitation is uncertain. Our objective was to assess the comparative effectiveness of these techniques in reducing or eliminating secondary tricuspid regurgitation.

Methods: From 1990 to 2008, 2277 patients underwent tricuspid valve procedures for secondary tricuspid regurgitation concomitantly with mitral (n = 1527, 67%), aortic (n = 180, 7.9%), or combined (n = 570, 25%) valve surgery. These included annulus (flexible prosthesis [n = 1052, 46%], rigid prosthesis [standard = 387, 3-dimensional = 197; 26%], Peri-Guard annuloplasty [Synovis Surgical Innovations, St Paul, Minn; n = 185, 8.1%], and De Vega suture [n = 129, 5.7%]), commissure (Kay [n = 248, 11%]), and leaflet (edge-to-edge suture [n = 79, 3.5%] +/- annulus or commissural) procedures. A total of 4745 postoperative transthoracic echocardiograms in 1965 patients were analyzed.

Results: By 3 months after surgery, only 32% of patients overall had no tricuspid regurgitation. However, by 5 years, this had decreased to 22%, and 3+/4+ tricuspid regurgitation had increased from 11% at 3 months to 17%. Patients with rigid ring annuloplasty alone, either standard or 3-dimensional, had the least increase of 3+/4+ tricuspid regurgitation (to 12% at 5 years) compared with either a commissural or leaflet procedure.

Conclusion: Rigid prosthetic ring annuloplasty, standard or 3-dimensional, provides early and sustained reduction of tricuspid regurgitation secondary to left-sided valve disease without need for an additional leaflet procedure. However, results are imperfect, possibly because other anatomic levels (subvalvular, papillary muscle, and right ventricular) contributing to its pathophysiology are unaddressed.