Concomitant Tricuspid Valve Repair Of Mild-to-moderate Tricuspid Regurgitation In The Minimally Invasive Mitral Patient
Mark R. Helmers, Samuel T. Kim, Jason J. Han, Amit Iyengar, Peter Altshuler, John Kelly, Benjamin Smood, W. Clark Hargrove, Pavan Atluri
University of Pennsylvania, Philadelphia, PA, USA
Background: Tricuspid regurgitation (TR) often stems from mitral insufficiency and the resulting dilation of the right ventricle - a condition that may improve on its own following mitral valve repair or replacement. While most patients with severe TR receive concomitant tricuspid procedures in addition to mitral valve surgery, significant debate exists around the benefit and outcomes of additional tricuspid valve repair in patients with mild-to-moderate TR at the time of minimally invasive mitral valve (mini-MV) surgery.
Methods: Retrospective analysis of our institution’s database of 8,181 mitral valve procedures - including 1,819 minimally invasive patients - was performed between November 1998 and March 2019 for all adult patients with mild-to-moderate TR undergoing mini-MV surgery. At our institution, consideration is given to concomitant TVR if mild-moderate TR is associated with severe tricuspid annular dilation. Patients were stratified by mini-MV surgery only (MVR) or MVR + tricuspid valve repair (MVR+TVR). Baseline characteristics and perioperative outcomes were compared between groups.
Results: Overall, 499 MV surgeries met inclusion criteria during the study period. Of these, 461 (92.4%) were isolated MVR and 38 (7.6%) MVR+TVR. Cardiopulmonary bypass (124 vs 179 min, P < 0.001), cross clamp times (88 vs 129 min, P < 0.001), and total operative times (219 vs 275 min, P < 0.001) were longer for the MVR+TVR group. Postoperatively, isolated MVR was associated with shorter initial ventilator times (6 vs 9.1 hrs, P < 0.001) as well as hospital (7 vs 8.5 days, P <0.001) and ICU (32 vs 48 hours, P = 0.013) lengths of stay. MVR+TVR procedures were more likely to require a pacemaker (2.4% vs 15.8%, P < 0.001) following surgery. 30-day mortality (1.1% vs 2.7%, P = 0.38) and 15-year survival (P = 0.80, see Figure 1) were similar between groups.
Conclusions:The addition of TV procedures to mini-MV surgery in patients with mild-to-moderate TR does not appear to improve either short-term or long-term survival. Moreover, the addition of concomitant TVR may predispose patients to increased operative times, longer recovery, and greater pacemaker rates. Further analysis of outcomes in this population is warranted. 
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