Evolving Approaches to Tricuspid Valve Surgery

Moving To Europe?

• tricuspid surgery guidelines

The tricuspid valve has sometimes been referred to as the “forgotten valve” because there are far more publications about mitral valve surgery than about tricuspid valve surgery. In this issue of the Journal, Chikwe et al. (1), from Mt. Sinai Medical Center in New York, provide an example of a new focus on the importance of adding tricuspid valve surgery to create a more comprehensive approach to patients needing mitral valve operations. Europe has been ahead of the United States in this regard for years, and, historically, European surgeons were more likely to perform tricuspid valve surgery concomitantly with mitral valve surgery. Indications for tricuspid valve surgery, according to guidelines from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (2), suggested a much more aggressive approach to tricuspid valve surgery than the U.S. guidelines (3,4). However, guidelines in the United States have evolved (5), and they now are similar to the European document. The approach described by Chikwe et al. reflects this change.

It is an easy decision to add tricuspid surgery for patients undergoing left-sided valve operations when there is severe tricuspid regurgitation (TR), especially if these patients have symptoms related to the tricuspid valve (Class I or Class IIa indications in all guidelines) (1–4). Chikwe et al. (1) suggest early repair of moderate TR or even when there is only mild TR in the presence of significant annular dilation (>40 mm); this approach results in a higher freedom from moderate TR at late follow-up compared with patients who had isolated mitral valve repair. Additional findings in these patients are improved recovery of right ventricular function and a reduction in pulmonary hypertension (1). Higher freedom from recurrent TR in treated patients has been described in other papers, as has improved late right ventricular function (6,7). A prospective randomized trial of patients with moderate TR, or less severe TR with a dilated annulus, showed that even with a relatively small group of patients (22 in each group), not only was freedom from recurrent moderate to severe TR better (0% vs. 28% in the untreated group; p = 0.02), but also clinical improvement was greater (8). The 6-min walk test improved from baseline in both groups, but the improvement was greater in the treatment group compared with the group treated with mitral valve surgery only (p = 0.008). Therefore, the myth that TR will resolve after mitral valve surgery has been disproven by many recent studies and belongs only in the history books.

We have to weigh the risks against the benefits of adding tricuspid valve surgery to mitral valve surgery. In the study by Chikwe et al. (1), there were no apparent added risks and no increase in permanent pacemaker use, and studies from the Society of Thoracic Surgery database indicate that the risks are now lower if tricuspid valve surgery is added to mitral valve surgery (9). Quantifying benefit is more difficult because patients show clinical benefit related to the mitral valve component of the surgical procedure. This study by Chikwe et al. (1) now adds to the growing literature demonstrating a benefit from the tricuspid valve surgery (6–8).

Unfortunately, the Society of Thoracic Surgery database, using guideline criteria, indicates that we fall far short of the number of tricuspid valve operations that should be employed, but at Mt. Sinai, 65% of patients undergoing mitral valve operations also had tricuspid valve surgery. Through deeper educational efforts and dissemination of data, we should expect to see this approach more widely adopted.

• American College of Cardiology Foundation