Prognosis

From a technical standpoint, tricuspid valve repair/replacement is not complex and can often be conducted on a warm, beating, perfused heart. There are only a few large series of operations done for isolated TR, in contrast to the more extensive literature on mitral regurgitation. Large series were published that included patients operated on primarily for left-sided cardiac pathologies but who also underwent incidental tricuspid valve procedure due to a range of tricuspid valve pathologies.[28][39] Several principles of treatment can be gleaned from the available literature on TR and tricuspid valve surgery.

Long-term outcome: all patients

Patients who require tricuspid valve operation constitute a high-risk group. Thirty-day mortality in patients who received concomitant tricuspid valve procedure in addition to the correction of other cardiac pathologies has been shown to be as high as 19%.[28] The high operative mortality is representative of the underlying cardiac pathology and is not necessarily reversed with successful operation. Outcomes mostly depend on concomitant cardiac pathologies.

Follow-up of patients at 30 years showed an actuarial survival of 12%.[39] The numbers have been representative of what amounts to an incurable valve disease.

Long-term outcome: recent advances

Outcomes related to a more recent year of operation suggest improved results. Operation before 1989 is a significant predictor of late death: 66% for operation before 1989 and 32% for operation after 1989.[39] The improved outcomes certainly represent important clinical, diagnostic, and surgical advances that have taken place. In addition, a better understanding of TR and its clinical presentation allow earlier diagnosis and treatment. Patients are much better served with operation before significant end-organ damage (i.e., cardiac cirrhosis) develops.

Repair versus replacement

Tricuspid valve repair is associated with better perioperative and long-term outcomes than valve replacement.[28][29] The authors of this monograph favor valve repair in patients with functional TR with relatively preserved heart function and normal pulmonary artery pressures.

Durability of valve repair

There is an important point to be made with respect to tricuspid valve repair: it does not always give a durable result.[29] Reoperation for failure of tricuspid valve repair is associated with high mortality, both perioperatively and in the long term.[40]

Risk factors for failure of valve repair

Risk factors for failure of tricuspid valve repair failure that have been investigated include:

  • Left and right ventricular function.[41]

  • Increased right and left ventricular pressures.[41]

However, it has been shown that there is no difference with respect to freedom from valve-related mortality and from tricuspid valve reoperation.[29]

Association with mitral valve regurgitation

Mitral regurgitation often results in secondary tricuspid annular dilation that may or may not be accompanied by TR. The resultant dilation is an ongoing disease process that can lead to severe TR and worse outcome if patients are not treated with concomitant tricuspid valve annuloplasty.[34][42] The authors of this monograph would recommend tricuspid annuloplasty in patients when the annulus is significantly dilated.[34]

Implications of restoration of sinus rhythm

TR is common in patients undergoing mitral valve surgery, and atrial fibrillation may cause progression of TR. A case-control study found that continued atrial fibrillation after mitral valve surgery may predispose a patient to progression of TR, and this progression may be prevented through correction of atrial fibrillation with the Maze procedure.[43]

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