Better Outcomes With Combined Tricuspid Intervention and Pulmonary Valve Replacement

By Will Boggs MD

March 03, 2020

NEW YORK (Reuters Health) - Adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) and significant tricuspid regurgitation have better tricuspid outcomes with combined tricuspid intervention and pulmonary valve replacement (PVR) than with isolated PVR, according to a retrospective study.

"We think that, for patients with TOF/PS evaluated for redo surgery and presenting with moderate to severe tricuspid regurgitation (TR), concomitant tricuspid valve intervention (TVI) should be routinely offered," Dr. Catherine Deshaies from Dalhousie University, Halifax, Nova Scotia and Universite de Montreal, Montreal, Quebec, Canada, told Reuters Health by email. "In those with mild TR but mechanisms unlikely to resolve with RV offloading and likely to respond to simple repair, tricuspid repair should be attempted without fear of major complications."

At the time of PVR, three-quarters of adult patients with repaired TOF/PS have at least mild TR and one-third have at least moderate TR, but the impact of TVI at the time of PVR remains highly debated.

Dr. Deshaies and colleagues used data from all eight university centers across Canada routinely performing pediatric and adult congenital cardiac procedures to evaluate the early clinical and echocardiographic outcomes of 542 adult congenital patients undergoing PVR with (n=180) or without (n=362) concomitant TVI.

Overall, tricuspid valvular competence improved by at least 1 grade in 35.4% of patients with mild preoperative TR, 66.9% of those with moderate preoperative TR, and 92.8% of patients with severe TR.

In multivariable analysis, concomitant TVI was independently associated with a 2.3-fold greater odds of improvement of TR by at least 1 grade, compared with isolated PVR.

Higher grade of preoperative TR and the presence of transvalvular pacemaker or defibrillator leads were independently associated with residual TR.

In the unadjusted analysis, the risk of early complication was 60% higher in patients who underwent combined PVR and TVI than in patients who underwent isolated PVR, but in adjusted multivariable analyses, there was no significant difference between the groups.

Combined PVR+TVI was also associated with a longer hospital stay in unadjusted analyses, but not in the final multivariable model, according to the report in the Journal of the American College of Cardiology.

"We hope that these findings will influence current surgical practices," Dr. Deshaies said. "Furthermore, we hope that our results will encourage pediatric and adult congenital cardiologists to pay closer attention to TR in the context of prior TOF/PS repair."

"We think that the function of this additional valve should be carefully monitored through the years and mechanisms of regurgitation precisely defined as they arise, so that all of this information can be taken into account at the time of reintervention and used to individualize care," she said.

Dr. Deshaies added, "Our findings also question the use of percutaneous isolated PVR in patients presenting with favorable anatomy but with significant TR. Young adults with corrected TOF/PS already at high-risk for right heart failure may benefit in the long run from a more comprehensive reintervention strategy addressing both PR and TR."

Dr. Fred H. Rodriguez III from Emory University School of Medicine, Atlanta, Georgia, who wrote an editorial related to this report, told Reuters Health by email, "Strong consideration should be given to addressing a regurgitant tricuspid valve during pulmonary valve replacement, especially if the tricuspid valve is structurally abnormal."

"The authors aim to answer a question that has been debated back and forth in the medical literature," he said. "The long-term results of both the tricuspid valve intervention and the pulmonary valve replacement are important for counseling and caring for patients."

Dr. Justin Tretter from Cincinnati Children's Hospital Medical Center in Ohio, whose research has included echocardiography in children and adults with congenital heart disease, told Reuters Health by email, "TVR appears not to add additional short-term adverse risk when performed at the time of PVR. It clearly reduces the degree of tricuspid regurgitation in those with moderate or severe tricuspid regurgitation more than PVR alone. However, this short-term observational study did not assess for functional improvement nor survival benefit."

"To properly understand whom TVR in addition to PVR may benefit, we would need to understand the mechanism of tricuspid regurgitation, and there would need to be a homogenous approach to TVR," he said. "In the current study, few patients with severe tricuspid regurgitation (n=4) only underwent PVR without TVR, making it difficult for any comparison in this severe tricuspid regurgitation group."

SOURCE: and Journal of the American College of Cardiology, online March 2, 2020.