Concomitant tricuspid valve repair during mitral surgery reduced severe TR progression and improved survival with 85% freedom from severe TR at 5 years versus 70% without repair.
Does surgical or transcatheter intervention improve outcomes in patients with rheumatic mitral disease and tricuspid regurgitation?
Optimal management of tricuspid regurgitation in rheumatic mitral disease requires individualized Heart Team decision-making, with conservative management for mild TR, concomitant repair for moderate TR, and surgical correction for severe TR.
Effect estimate: hazard ratio (HR) 0.61 for survival benefit with repair; odds ratio (OR) 0.08 for TR progression with repair (95% CI HR 0.61 (95% CI 0.45–0.84); OR 0.08 (95% CI 0.05–0.16) for TR progression)
Absolute Event Rate: 85% vs 70%
p-value: p=.038 in one retrospective cohort for increased recurrence with replacement vs repair
Background: Rheumatic heart disease (RHD) remains a major cause of cardiovascular morbidity and mortality in low and middle-income countries, with tricuspid regurgitation (TR) frequently complicating rheumatic mitral pathology. While mild TR often stabilizes after mitral correction, management of moderate and severe TR in this context remains controversial due to limited evidence and applicability of guidelines largely derived from degenerative etiologies. This review synthesizes current data on diagnostic strategies, surgical decision-making, and outcomes in rheumatic TR. Methods: A comprehensive literature search was performed across PubMed, Google Scholar, and OMNI databases (2010-2024) using the keywords "rheumatic mitral disease," "tricuspid regurgitation," and "management." Eligible studies included clinical trials, case series, reviews, and meta-analyses focusing on TR associated with rheumatic mitral disease. Data was extracted and critically appraised for study design, population, and outcome relevance. Results: Evidence for managing TR in rheumatic mitral disease primarily stems from retrospective cohorts and small prospective studies, with few randomized trials. Predictors of TR progression include annular dilation (>21 mm/m²), right ventricular dysfunction, pulmonary hypertension, and atrial fibrillation. Mild TR generally regresses following mitral surgery and is managed conservatively. For moderate TR, concomitant repair may prevent late progression and improve hemodynamics, though risks of postoperative arrhythmia and pacemaker implantation persist. Severe TR warrants surgical correction, preferably rigid ring annuloplasty, while valve replacement is reserved for advanced calcific disease. Emerging transcatheter therapies show promise for high-risk patients but lack robust rheumatic-specific data. Conclusion: Optimal management of TR in rheumatic mitral disease requires individualized, Heart Team-based decision-making due to limited high-quality evidence. Future research should prioritize multicenter trials comparing repair, replacement, and transcatheter approaches, integrating advanced imaging for risk stratification and addressing access disparities in resource-limited settings.
Kalasipudi et al. (Wed,) conducted a review in Patients with rheumatic mitral valve disease complicated by tricuspid regurgitation (mild, moderate, or severe). Concomitant tricuspid valve repair during mitral valve surgery vs. Mitral valve surgery alone without tricuspid repair was evaluated on Freedom from severe tricuspid regurgitation and survival after mitral valve surgery with or without concomitant tricuspid repair (hazard ratio (HR) 0.61 for survival benefit with repair; odds ratio (OR) 0.08 for TR progression with repair, 95% CI HR 0.61 (95% CI 0.45–0.84); OR 0.08 (95% CI 0.05–0.16) for TR progression, p=.038 in one retrospective cohort for increased recurrence with replacement vs repair). Concomitant tricuspid valve repair during mitral surgery reduced severe TR progression and improved survival with 85% freedom from severe TR at 5 years versus 70% without repair.