Tricuspid valve repair during mitral valve surgery may benefit some patients

In an international study of more than 400 adults, mitral valve surgery (between the left atrium and the left ventricle of the heart) was performed and the tricuspid valve (the part that pumps blood from the heart) was not severely leaked. I conclude that. The right atrium to the ventricles) may benefit from repairing both valves at the same time. The study found that simultaneous repair reduced the risk of severe tricuspid valve leakage in the future.

The results of the clinical trial were presented at the American Heart Association’s Annual Science Session Conference on November 13.The full study was published at the same time New England Journal of Medicine..

Heart valves play a role in regulating blood flow between the four ventricles of the heart. The valve has a leaflet, a thin but strong tissue flap that helps prevent blood from flowing back into the heart. When a valve leaks, it is known as backflow. Symptoms of such leaks include shortness of breath, malaise, and dizziness.

Leaky mitral valves are the most common type of heart valve abnormality and are most often repaired or replaced by surgery. In the United States, more than 50,000 surgeries are performed each year to repair mitral regurgitation.

To repair the tricuspid valve, a ring is implanted around the valve to treat and prevent the progression of leaks and the accumulation of fluid in the heart. This is an independent risk factor for increased long-term mortality risk.

There is a general agreement among surgeons that if there is a severe leakage of the tricuspid valve, it needs to be corrected. However, there was considerable uncertainty as to whether tricuspid valve repair was necessary during mitral valve surgery with moderate or less leakage. “

James Gummy, Principal Investigator, Surgical Leader, and Co-Director, The Cardiovascular Institute, Johns Hopkins University School of Medicine, Maryland

To study the potential efficacy and safety of less than moderate tricuspid valve repair during mitral valve surgery, researchers in 39 locations in the United States, Canada, and Germany between 2016 and 2018. An international multicenter randomized controlled trial was conducted. Included in the study. 203 had only mitral valve surgery, while 198 had mitral valve surgery and tricuspid valve repair. Participants were predominantly Caucasian males (91% white, 75% male), averaging 67 years. Researchers assessed mortality, repeated surgery for tricuspid regurgitation, and progression of tricuspid valve leakage.

After two years of follow-up of the participants, the researchers found that, overall, those who repaired both mitral and tricuspid valve problems at the same time had less progression to moderate or severe leakage and were treated. It was more successful than those who repaired only the mitral valve, which they found to have experienced better results, such as improvement.

Key findings of the study:

• Only 3.4% of those who had both valves repaired progressed to moderate or severe tricuspid regurgitation after 2 years, compared to 25% of those who underwent mitral valve surgery alone.
• Less than 1% (0.6%) of patients with both valves fixed progressed to severe tricuspid regurgitation after 2 years, compared to 5.6% of patients in the mitral valve-only surgery group.
• The treatment failure rate defined as mortality and / or reoperation in tricuspid valve surgery was higher in the group that did not fix the tricuspid valve at the same time as mitral valve surgery compared to the group that fixed it (10.2). %). %).

Participants who underwent modern mitral valve surgery had a mortality rate of less than 1% and a survival rate of over 96% after 2 years. Repairing the tricuspid valve during mitral valve surgery can limit leakage and cause damage to the heart, but researchers have also found the following drawbacks:

• Adding tricuspid valve repair increased surgery time and time spent on heart-lung machine by 34 minutes.
• A permanent pacemaker was required in 14% of patients in the tricuspid valve repair group, compared to 2.5% of patients who underwent mitral valve surgery alone. Researchers say this didn’t seem to have a negative effect on the patient.
• The median length of stay for patients was increased by two days.

“We need to have a clear understanding of the risk factors that require a permanent pacemaker to be implanted after tricuspid valve repair and how to best mitigate risk with technological changes and various postoperative management strategies,” Gammie said. I am saying. “But for the first time, there is a high level of evidence to help us understand what to do in the operating room when it comes to repairing the tricuspid valve in people with less severe regurgitation.”

According to Gammie, the study is designed to keep patients up to 5 years after surgery to see if tricuspid valve leakage progresses further.