Should annular dilation be a marker for concomitant tricuspid valve repair?

In their invited commentary, Dr. Tirone E. David of the University of Toronto and his colleagues said that performing a tricuspid valve annuloplasty (TVA) in the setting of tricuspid regurgitation (TR) or a tricuspid annulus diameter greater than 40 mm does not completely prevent the onset of new TR (J Thorac Cardiovasc Surg. 2015 Nov;150:1043-4). “Other factors play a role in its development,” they said. “Longstanding atrial fibrillation is one of them.”

“Are patients who have mitral valve (MV) repair for degenerative disease of the MV likely to develop functional TR if there is only trivial or mild TR before surgery?” Dr. David and his coauthors asked. “We are certain that some patients do, but it does not appear to be as common as patients who had MV replacement for rheumatic disease. Is it solely because the incidence of atrial fibrillation is higher in rheumatic patients?”

In a second invited commentary, Dr. Richard J. Shemin of the University of California, Los Angeles, said the discrepancies between the rates of concomitant tricuspid repair among the various centers that Dr. Robert A. Dion cited beg for resolution (J Thorac Cardiovasc Surg. 2015 Nov;150:1045-6). “The wide discrepancy can perhaps be partially resolved with a re-review of the Toronto experience and follow-up,” Dr. Shemin said. “The subset of patients with TVA greater than 40 who were not repaired and the late follow-up would be very helpful.”

The cardiothoracic surgeon faces conflicting principles when considering concomitant tricuspid valve repair, Dr. Shemin said: avoiding an unnecessary surgery when functional TR exists, or leaving a residual lesion that could lead to a risky reoperation. Hence, accurate measurements of the tricuspid valve annulus and TR are essential, Dr. Shemin said.

“The tricuspid valve has been rediscovered and further investigation will resolve the questions,” Dr. Shemin said. Likewise, Dr. David and his colleagues said the “time has come” for a multicentered clinical trial to put the issue to rest for both mitral valve replacement and repair.