P1598Tricuspid valve repair at the time of mitral valve surgery is safe and reduces the incidence of late tricuspid regurgitation and reoperation: a meta-analysis

Abstract

Background: The surgical management of tricuspid regurgitation (TR) at the time of mitral valve surgery remains controversial. The incidence of tricuspid valve repair (TVR) during mitral valve surgery ranges from 7% to 65% in the literature. Our objectives were to determine the safety and efficacy of TVR during mitral valve repair or replacement in a meta-analysis. Methods: MEDLINE and EMBASE was searched from 1946 to 2017 for all studies comparing TVR (TVR+) to no TVR (TVR-) at the time of mitral valve surgery on early and late mortality and late TR. A random-effects meta-analysis of all outcomes was performed. Short term binary outcomes were pooled as risk ratios (RR) and late outcomes were pooled as incident rate ratios (IRR) to account for differences in follow-up between groups. Results: 1417 studies were retrieved and a total of 19 studies (one randomized clinical trial (RCT, n=44), six adjusted observational studies (n=2389) and 12 unadjusted observational studies (n=67,814)) were included in the final analysis that compared TVR+ (n=11,787) to TVR-(n=56,027) at a mean follow-up of 5.0 years. The indication(s) for TVR were: any TR with an enlarged annulus (n=6), moderate or less TR (n=5), moderate or more (n=5), any TR (n=3). The majority of patients underwent repair with an annuloplasty ring while a minority underwent suture annuloplasty. There was no difference in 30-day/in-hospital mortality between TVR+ and TVR-(RR: 1.31 95% confidence interval (95% CI): 0.85, 2.02, p=0.25). The incidence of new permanent pacemaker implantation was higher in the TVR+ group (RR: 2.73, 95% CI: 2.57, 2.89, p<0.01). TVR+ was protective against late moderate to severe TR (IRR: 0.26, 95% CI: 0.16, 0.43; p<0.01) and severe TR (IRR: 0.32, 95% CI: 0.11, 0.91, p=0.03). There was a trend towards a lower rate of late TV reoperation in a pooled analysis of five studies (IRR: 0.36, 95% CI: 0.13,1.02; p=0.06). Overall, there was no difference in late mortality between TVR+ and TVR-(Figure - IRR: 0.87, 95% CI: 0.63, 1.20 p=0.39). Conclusions: TVR at the time of mitral valve surgery was not associated with peri-operative mortality but a more than double the risk of permanent pacemaker implantation. At late follow-up, TVR was associated with less than moderate or severe TR with a trend towards less repeat TV-related reoperation reported in a limited number of studies. However, there was no difference in late mortality at 5 years. TVR appears safe in the post-operative period and may reduce the need for future reoperation without survival benefit.