JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 77, NO. 6, 2021 ª 2021 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation a, b, a a Philippe B. Bertrand, MD, PHD, * Jessica R. Overbey, DRPH, * Xin Zeng, MD, PHD, Robert A. Levine, MD, c d e f b Gorav Ailawadi, MD, Michael A. Acker, MD, Peter K. Smith, MD, Vinod H. Thourani, MD, Emilia Bagiella, PHD, Marissa A. Miller, DVM, MPH,g Lopa Gupta, MPH,b Michael J. Mack, MD,h A. Marc Gillinov, MD,i b b b j Gennaro Giustino, MD, Alan J. Moskowitz, MD, Annetine C. Gelijns, PHD, Michael E. Bowdish, MD, Patrick T. O’Gara, MD,k James S. Gammie, MD,l Judy Hung, MD,a on behalf of the Cardiothoracic Surgical Trials Network (CTSN) ABSTRACT BACKGROUND Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain. OBJECTIVES The goal of this study was to investigate the incidence, predictors, and clinical significance of TR pro- gression and presence of $moderate TR after IMR surgery. METHODS Patients (n ¼ 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by $2 grades, surgery for TR, or severe TR at 2 years) and presence of $moderate TR at 2 years. RESULTS Patients’ mean age was 66 Æ 10 years (67% male), and TR distribution was 60% #trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had $moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of $moderate TR. However, TAD alone had poor discrimination (area under the curve, #0.65). Presence of $moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p ¼ 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p ¼ 0.01). Clinical event rates (composite of $1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p ¼ 0.003) and $moderate TR at 2 years (38% vs. 22%; p ¼ 0.04). CONCLUSIONS After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not pre- dictive of TR progression and is poorly discriminative of $moderate TR at 2 years. TR progression and presence of $moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart’s Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040) (J Am Coll Cardiol 2021;77:713–24) © 2021 by the American College of Cardiology Foundation. From the aDivision of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; bDepartment of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA; cSection of Adult Cardiac Surgery, Listen to this manuscript’s University of Virginia, Charlottesville, Virginia, USA; dDivision of Cardiovascular Surgery, Department of Surgery, University of audio summary by Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA; eDepartment of Surgery, Duke University Medical Center, Editor-in-Chief Durham, North Carolina, USA; fCardiothoracic Surgery, Piedmont Heart Institute, Atlanta, Georgia, USA; gDivision of Cardiovas- Dr. Valentin Fuster on cular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA; hCardiothoracic JACC.org. Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, Texas, USA; iDepartment of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA; jDepartment of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; kCardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA; and the lDivision of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA. *Drs. Bertrand and Overbey served as joint first authors and contributed to the work equally. Erin Iannacone, MD, served as Guest Associate Editor for this paper. Athena Poppas, MD, served as Guest Editor-in-Chief for this paper. ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2020.11.066 Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en febrero 15, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. 714 Bertrand et al. JACC VOL. 77, NO. 6, 2021 TR Progression After IMR Surgery FEBRUARY 16, 2021:713– 24 ABBREVIATIONS rogression of tricuspid regurgitation echocardiographic, and procedural predictors of TR AND ACRONYMS P (TR) after mitral valve (MV) surgery progression and $moderate TR were evaluated, as is associated with significant well as the clinical impact of TR progression CABG = coronary artery bypass $ grafting morbidity, yet the optimal indications for and moderate TR after IMR surgery. treating TR at time of MV surgery remain un- ICD = implantable METHODS cardioverter-defibrillator clear (1–4). Current guidelines recommend IMR = ischemic mitral valve concomitant tricuspid valve repair in cases PATIENT POPULATION. regurgitation of moderate or more pre-operative TR, or in The patient population originates from 2 randomized surgical trials in pa- MACE = major adverse clinical cases of pre-operative tricuspid annular dila- events tion (>40 mm or 21 mm/m2)inpatientswith tients with IMR conducted by the CTSN, as previously – fl MR = mitral regurgitation only mild TR (Class IIa) (5,6). A prospectively described (10 13). Brie y, a total of 301 patients with MV = mitral valve randomized trial investigating this strategy moderate IMR were randomized to receive coronary artery bypass grafting (CABG) alone versus CABG þ ROC = receiver-operating in patients with primary mitral regurgitation characteristic (MR) is ongoing (NCT02675244). However, MV repair, and 251 patients with severe IMR were Æ RV = right ventricular in patients with ischemic mitral valve regur- randomized to undergo MV repair CABG versus MV Æ TR = tricuspid regurgitation gitation (IMR), data on TR progression after replacement CABG. The trials were conducted in 26 MV surgery are limited (7–9). The reported incidence and 22 centers, respectively, with a coordinating of significant ($moderate) TR after IMR surgery in a center, an independent clinical events committee retrospective series is as high as 50% at 1 to 3 years adjudicating mortality and adverse events, and a data (7). Prospective confirmation of this high incidence and safety monitoring board that oversaw trial prog- ’ is lacking. Given the important pathophysiological ress. Participating centers Institutional Review differences, results from the ongoing trial in primary Boards approved the protocol, and all patients signed MR cannot be extrapolated to surgery for ischemic a written informed consent. Complete inclusion and MR. Moreover, the value of the pre-operative exclusion criteria have been previously reported. tricuspid annular dimension to predict TR progression In the current analysis, all patients who had mod- in an ischemic heart disease population is unclear. erate or less TR without concomitant tricuspid inter- vention at the time of IMR surgery within both trials SEE PAGE 725 were included for analysis. Figure 1 shows the study In 2 prospective National Heart, Lung, and Blood population. Institute–supported Cardiothoracic Surgical Trials ECHOCARDIOGRAPHY. All echocardiographic exam- Network (CTSN) trials investigating surgery for mod- inations were reviewed and analyzed by an inde- erate or severe IMR, a selective approach toward pendent central core laboratory. Measures of left concomitant tricuspid valve repair was adopted and ventricular function and MR were assessed according left to the discretion of the surgeon (10,11). Tricuspid to international recommendations (14–16). TR was valve surgery was performed in <8% of the patients graded as none/trace, mild, moderate, or severe by undergoing surgery for IMR, and 92% of patients had using an integrative approach (15,16). Parameters no concomitant intervention at the level of the used to grade TR included: 1) the vena contracta tricuspid valve. Within these trials, serial echocardi- width; 2) the radius of proximal flow conversion; and ography, including dedicated tricuspid valve and 3) qualitative assessment of the color flow TR jet, the right ventricular (RV) assessment, was performed at density and shape of the continuous wave TR signal, baseline, 6 months, 1 year, and 2 years and analyzed and, when available, the hepatic vein flow signal. by an independent central core laboratory. The tricuspid annular diameter was measured in The purpose of the current analysis was to assess late diastole in a standard apical 4-chamber view, as the rate of TR progression from pre-operative base- recommended (17). Tricuspid annular dilation lineandthepresenceof$moderate TR at 2 years after was defined as an annular dimension $40 mm or IMR surgery