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VIENNA – One of the best ways to prevent advanced tricuspid-valve regurgitation and need for tricuspid-valve repair may be a more aggressive approach to mitral valve repair.
“If you operate on the mitral valve early, then tricuspid regurgitation does not tend to progress,” Dr. Sunil V. Mankad said at the annual meeting of the European Association of Cardiovascular Imaging. “If you wait until the mitral valve remodels and the atrium enlarges and remodels or there is pulmonary hypertension, then tricuspid regurgitation will progress,” said Dr. Mankad, a echocardiographer at the Mayo Clinic in Rochester, Minn.
Early intervention on mitral valve prolapse has other benefits as well, he said. Mitral disease causes atrial remodeling, which can then progress to atrial fibrillation, “and once that happens it’s a game changer for the patient, even if they later undergo valve repair,” because of atrial fibrillation’s long-term risks and consequences, Dr. Mankad said in an interview.
“We believe there is also subclinical left ventricular dysfunction” in patients with mitral-valve prolapse “even if their ejection fraction is normal.” Once that happens, even if the mitral valve is repaired “the heart is not normal anymore and there is subtle left ventricular dysfunction that is not captured by just looking at ejection fraction.”
To document the impact a more aggressive approach to mitral-valve repair can have on the tricuspid valve, Dr. Mankad cited a 2011 Mayo Clinic analysis of 699 patients who underwent mitral-valve repair at Mayo for severe mitral-valve prolapse and also had some amount of tricuspid regurgitation at the time of their surgery, including 115 patients (16%) with grade 3 or higher tricuspid regurgitation. One year after surgery, the severity of tricuspid regurgitation in these patients had decreased significantly overall, and throughout follow-up only one patient required surgery for tricuspid-valve repair, 4.5 years after that patient’s mitral-valve repair (J. Thoracic Cardiovasc. Surgery 2011;142:608-13).
Dr. Mankad also cited a recent editorial written by several of his Mayo Clinic colleagues that synthesized results from the 2011 report as well as from a second Mayo report published in 2014, and a third report from a different group also published in 2014. The authors of the editorial concluded that results from all three studies showed “the performance of early correction of mitral regurgitation is important not only for its own well known benefits (preservation of survival and minimization of late heart failure risk) but also to diminish the late occurrence of functional tricuspid regurgitation (J. Thoracic Cardiovasc. Surgery 2014;148:2810-2).
Because mitral-valve repair often improves tricuspid-valve function and durability, the editorialists suggested “strongly considering” tricuspid repair for a carefully defined, select subgroup of patients. Their list included patients with tricuspid regurgitation that is worse than moderate, right-heart dysfunction, symptoms of right-heart failure, pulmonary hypertension, reduced left ventricular systolic function, cardiomyopathy, or organic tricuspid pathology.
Existing evidence supports leaving the valve alone when patients have a tricuspid regurgitation that is less than moderate when they have also undergone effective correction of degenerative mitral regurgitation. Patients like these are “unlikely ever to have difficulty with the tricuspid valve or the right ventricle,” wrote the authors of the editorial.
Dr. Mankad offered his own suggestions for identifying patients with a tricuspid valve that requires repair at the time of mitral-valve surgery.
“The evidence supports tricuspid-valve repair at the time of mitral-valve surgery if there is tricuspid annular dilatation of more than 4.0 cm measured by three-dimensional echo or greater than moderate tricuspid regurgitation. This is based on observational data and not on results from randomized control trials, but it is what I recommend,” Dr. Mankad said. “I suggest measuring the tricuspid annulus; it is quite easy to do. Directly measuring the annulus size with three-dimensional echo is pretty basic, and I think it is ready for prime time.”
Dr. Mankad had no disclosures.
On Twitter @mitchelzoler
VIENNA – One of the best ways to prevent advanced tricuspid-valve regurgitation and need for tricuspid-valve repair may be a more aggressive approach to mitral valve repair.
“If you operate on the mitral valve early, then tricuspid regurgitation does not tend to progress,” Dr. Sunil V. Mankad said at the annual meeting of the European Association of Cardiovascular Imaging. “If you wait until the mitral valve remodels and the atrium enlarges and remodels or there is pulmonary hypertension, then tricuspid regurgitation will progress,” said Dr. Mankad, a echocardiographer at the Mayo Clinic in Rochester, Minn.
Early intervention on mitral valve prolapse has other benefits as well, he said. Mitral disease causes atrial remodeling, which can then progress to atrial fibrillation, “and once that happens it’s a game changer for the patient, even if they later undergo valve repair,” because of atrial fibrillation’s long-term risks and consequences, Dr. Mankad said in an interview.
“We believe there is also subclinical left ventricular dysfunction” in patients with mitral-valve prolapse “even if their ejection fraction is normal.” Once that happens, even if the mitral valve is repaired “the heart is not normal anymore and there is subtle left ventricular dysfunction that is not captured by just looking at ejection fraction.”
To document the impact a more aggressive approach to mitral-valve repair can have on the tricuspid valve, Dr. Mankad cited a 2011 Mayo Clinic analysis of 699 patients who underwent mitral-valve repair at Mayo for severe mitral-valve prolapse and also had some amount of tricuspid regurgitation at the time of their surgery, including 115 patients (16%) with grade 3 or higher tricuspid regurgitation. One year after surgery, the severity of tricuspid regurgitation in these patients had decreased significantly overall, and throughout follow-up only one patient required surgery for tricuspid-valve repair, 4.5 years after that patient’s mitral-valve repair (J. Thoracic Cardiovasc. Surgery 2011;142:608-13).
Dr. Mankad also cited a recent editorial written by several of his Mayo Clinic colleagues that synthesized results from the 2011 report as well as from a second Mayo report published in 2014, and a third report from a different group also published in 2014. The authors of the editorial concluded that results from all three studies showed “the performance of early correction of mitral regurgitation is important not only for its own well known benefits (preservation of survival and minimization of late heart failure risk) but also to diminish the late occurrence of functional tricuspid regurgitation (J. Thoracic Cardiovasc. Surgery 2014;148:2810-2).
Because mitral-valve repair often improves tricuspid-valve function and durability, the editorialists suggested “strongly considering” tricuspid repair for a carefully defined, select subgroup of patients. Their list included patients with tricuspid regurgitation that is worse than moderate, right-heart dysfunction, symptoms of right-heart failure, pulmonary hypertension, reduced left ventricular systolic function, cardiomyopathy, or organic tricuspid pathology.
Existing evidence supports leaving the valve alone when patients have a tricuspid regurgitation that is less than moderate when they have also undergone effective correction of degenerative mitral regurgitation. Patients like these are “unlikely ever to have difficulty with the tricuspid valve or the right ventricle,” wrote the authors of the editorial.
Dr. Mankad offered his own suggestions for identifying patients with a tricuspid valve that requires repair at the time of mitral-valve surgery.
“The evidence supports tricuspid-valve repair at the time of mitral-valve surgery if there is tricuspid annular dilatation of more than 4.0 cm measured by three-dimensional echo or greater than moderate tricuspid regurgitation. This is based on observational data and not on results from randomized control trials, but it is what I recommend,” Dr. Mankad said. “I suggest measuring the tricuspid annulus; it is quite easy to do. Directly measuring the annulus size with three-dimensional echo is pretty basic, and I think it is ready for prime time.”
Dr. Mankad had no disclosures.
On Twitter @mitchelzoler
VIENNA – One of the best ways to prevent advanced tricuspid-valve regurgitation and need for tricuspid-valve repair may be a more aggressive approach to mitral valve repair.
“If you operate on the mitral valve early, then tricuspid regurgitation does not tend to progress,” Dr. Sunil V. Mankad said at the annual meeting of the European Association of Cardiovascular Imaging. “If you wait until the mitral valve remodels and the atrium enlarges and remodels or there is pulmonary hypertension, then tricuspid regurgitation will progress,” said Dr. Mankad, a echocardiographer at the Mayo Clinic in Rochester, Minn.
Early intervention on mitral valve prolapse has other benefits as well, he said. Mitral disease causes atrial remodeling, which can then progress to atrial fibrillation, “and once that happens it’s a game changer for the patient, even if they later undergo valve repair,” because of atrial fibrillation’s long-term risks and consequences, Dr. Mankad said in an interview.
“We believe there is also subclinical left ventricular dysfunction” in patients with mitral-valve prolapse “even if their ejection fraction is normal.” Once that happens, even if the mitral valve is repaired “the heart is not normal anymore and there is subtle left ventricular dysfunction that is not captured by just looking at ejection fraction.”
To document the impact a more aggressive approach to mitral-valve repair can have on the tricuspid valve, Dr. Mankad cited a 2011 Mayo Clinic analysis of 699 patients who underwent mitral-valve repair at Mayo for severe mitral-valve prolapse and also had some amount of tricuspid regurgitation at the time of their surgery, including 115 patients (16%) with grade 3 or higher tricuspid regurgitation. One year after surgery, the severity of tricuspid regurgitation in these patients had decreased significantly overall, and throughout follow-up only one patient required surgery for tricuspid-valve repair, 4.5 years after that patient’s mitral-valve repair (J. Thoracic Cardiovasc. Surgery 2011;142:608-13).
Dr. Mankad also cited a recent editorial written by several of his Mayo Clinic colleagues that synthesized results from the 2011 report as well as from a second Mayo report published in 2014, and a third report from a different group also published in 2014. The authors of the editorial concluded that results from all three studies showed “the performance of early correction of mitral regurgitation is important not only for its own well known benefits (preservation of survival and minimization of late heart failure risk) but also to diminish the late occurrence of functional tricuspid regurgitation (J. Thoracic Cardiovasc. Surgery 2014;148:2810-2).
Because mitral-valve repair often improves tricuspid-valve function and durability, the editorialists suggested “strongly considering” tricuspid repair for a carefully defined, select subgroup of patients. Their list included patients with tricuspid regurgitation that is worse than moderate, right-heart dysfunction, symptoms of right-heart failure, pulmonary hypertension, reduced left ventricular systolic function, cardiomyopathy, or organic tricuspid pathology.
Existing evidence supports leaving the valve alone when patients have a tricuspid regurgitation that is less than moderate when they have also undergone effective correction of degenerative mitral regurgitation. Patients like these are “unlikely ever to have difficulty with the tricuspid valve or the right ventricle,” wrote the authors of the editorial.
Dr. Mankad offered his own suggestions for identifying patients with a tricuspid valve that requires repair at the time of mitral-valve surgery.
“The evidence supports tricuspid-valve repair at the time of mitral-valve surgery if there is tricuspid annular dilatation of more than 4.0 cm measured by three-dimensional echo or greater than moderate tricuspid regurgitation. This is based on observational data and not on results from randomized control trials, but it is what I recommend,” Dr. Mankad said. “I suggest measuring the tricuspid annulus; it is quite easy to do. Directly measuring the annulus size with three-dimensional echo is pretty basic, and I think it is ready for prime time.”
Dr. Mankad had no disclosures.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM EUROECHO-IMAGING 2014
