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Concomitant tricuspid annuloplasty reduces treatment failure in moderate tricuspid regurgitation

Presented by
Prof. James Gammie, University of Maryland, USA
AHA 2021
Tricuspid annuloplasty during mitral valve surgery (MVS) in patients with moderate or mild tricuspid regurgitation resulted in a decreased treatment failure compared with patients who did not receive tricuspid repair during MVS. However, an increased risk of permanent pacemaker implantation was observed in patients receiving tricuspid annuloplasty during MVS.

“It is common to perform tricuspid repair during MVS in patients with mitral regurgitation and severe TR. However, there is a large variability in clinical practice regarding the threshold for performing surgery in patients with mild or moderate tricuspid regurgitation,” argued Prof. James Gammie (University of Maryland, MD, USA) [1]. Thus, the current trial investigated concomitant, undersized, rigid, non-planar tricuspid annuloplasty during MVS in patients with less than severe tricuspid regurgitation. Participants were randomised 1:1 to MVS alone (n=203) or MVS plus tricuspid annuloplasty (n=198). The primary endpoint was treatment failure at 2 years, defined as the composite of death, re-operation for tricuspid regurgitation, or tricuspid regurgitation progression from baseline.

At 2 years, treatment failure was reduced in the MVS plus tricuspid annuloplasty arm (3.9%) compared with the MVS alone arm (10.2%; RR 0.37; P=0.02). Subgroup analysis revealed that the difference in treatment failure between surgery groups was more pronounced in patients with moderate tricuspid regurgitation (18.1% vs 4.5%; RR 0.25; 95% CI 0.07–0.83) than in patients with less than moderate tricuspid regurgitation (6.1% vs 3.4%; RR 0.56; 95% CI 0.17–1.87). In addition, the effect was driven by tricuspid regurgitation progression from baseline and not by death or re-operation for tricuspid regurgitation. The proportion of participants with moderate or severe tricuspid regurgitation after 2 years of follow-up was higher in the MVS group (25.1%) than in the MVS plus tricuspid annuloplasty group (3.4%; RR 0.13; 95% CI 0.06-0.30). Notably, the risk of permanent pacemaker implantation was increased in the MVS plus tricuspid annuloplasty arm (14.1%) versus the MVS alone arm (2.5%). No difference was observed in all-cause mortality, quality of life, or major adverse cardiovascular or cerebrovascular events (MACCE).

Dr Gammie added that the 2-year endpoint may be too short to determine the long-term effects of tricuspid annuloplasty in this population. Thus, long-term follow-up is being performed to weigh the clinical benefits of this procedure against the cost of an increased risk of permanent pacemaker implantation.


    1. Gammie JS, et al. Evaluating the benefit of concomitant tricuspid repair during mitral valve surgery. LBS01, AHA Scientific Session 2021, 13–15 November.


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