Search

Objectives: Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines. Methods: All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm). Results: Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all P ≥ .2) except for more atrial fibrillation and larger left ventricle (both P ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all P ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all P ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], P = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), P = .09. for patients with TA versus without. Conclusions: In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.

OBJETIVO: O propósito deste estudo é demonstrar que o reposicionamento do músculo papilar é uma técnica confiável para o reparo do prolapso da cúspide anterior, portanto, nós descrevemos esta técnica e seus resultados propondo-a como padrão. MÉTODO: Entre 1989 e 2005, 120 plastias da valva mitral foram consecutivamente realizadas por meio do reposicionamento do músculo papilar no prolapso da cúspide anterior. Oitenta e sete pacientes eram do sexo masculino e 33 do feminino, sendo, a média de idade de 59 ± 11,5 anos. Cinqüenta e nove por cento dos pacientes estavam em classe funcional (NYHA) III ou IV, a média da fração de ejeção foi 65,7 ± 8,9%. A etiologia predominante na regurgitação da valva mitral (RM) foi doença degenerativa: Barlow (n=43) e distrofia (n=62). As outras etiologias eram: endocardite cicatrizada (n=5), reumática (n=5), isquêmica (n=4), congênita (n=1). O reposicionamento do músculo papilar posterior foi realizado em 111 (92,5%) casos e do anterior em 38 (31,7%). Procedimentos associados foram realizados em 76 (63,3%) pacientes. RESULTADOS: Não houve óbito hospitalar. Durante o acompanhamento, 14 (11,7%) pacientes foram a óbito, incluindo sete (5,8%) por causas cardíacas. As taxas da curva de sobrevida acumulada em 1, 5, 10 e 15 anos foram 98,3%, 97,2%, 94,1% e 81,4%, respectivamente. Dois (1,7%) pacientes foram reoperados por regurgitação recorrente, eles foram submetidos à troca da valva 1 e 5 anos depois do reparo e morreram 3 e 6 anos após esta troca valvar. Não houve movimento anterior sistólico. As taxas de sobrevida acumulada livre de reoperação envolvendo a valva mitral em 1, 5, 10, e 15 anos foram 97,4%, 97,4%, 92,8% e 86,7%, respectivamente. Nós não achamos nenhum fator de risco de mortalidade e de reoperação. O acompanhamento completo foi realizado em todos os pacientes. Após um tempo de acompanhamento mediano de 5,9 anos (de 0,1 a 15,6 anos), 87 (72,5%) pacientes estavam na classe I - NYHA, o controle ecocardiográfico mostrou nenhuma ou mínima regurgitação em 89 (74,2 %) pacientes, leve regurgitação em oito (6,7%) e moderada regurgitação em nove (7,5%). CONCLUSÃO: O reposicionamento do músculo papilar é uma técnica confiável e segura, com excelentes resultados clínicos e ecocardiográficos a longo prazo. Desta maneira, estamos propondo-a como padrão para o reparo da cúspide anterior prolapsada.OBJECTIVE: The aim of this study was to demonstrate that papillary muscle repositioning is a reliable technique to repair anterior leaflet prolapse. Therefore we describe this technique and its long term results to propose it as a gold standard. METHOD: Between 1989 and 2005, 120 mitral valve repairs were consecutively performed using papillary muscle repositioning in cases of anterior leaflet prolapse. There were 87 males and 33 females, the mean age was 59 ± 11.5 years. 59% of patients were in NYHA III or IV. Mean ejection fraction was 65.7 ± 8.9%. Predominant aetiology of mitral regurgitation (MR) was degenerative: Barlow (n=43) and dystrophic (n=62). The other aetiologies were: healed endocarditis (n=5), rheumatic (n=5), ischemic (n=4), congenital (n=1). A posterior papillary muscle repositioning was performed in 111 (92.5%) cases and an anterior in 38 (31.7%). Associated procedures were carried out in 76 (63.3%) patients. RESULTS: There were no in-hospital deaths. During the follow-up, 14 patients (11.7%) died, including seven (5.8%) due to cardiac causes. The cumulated survival rates at 1, 5, 10 and 15 years were 98.3%, 97.2%, 94.1% and 81.4% respectively. Two patients (1.7%) were reoperated for recurrency of the regurgitation, they underwent a replacement of the valve 1 and 5 years after the repair and died 3 and 6 years, respectively after this replacement. There was no systolic anterior motion. The cumulated survival rates free from reoperation involving the mitral valve at 1, 5, 10 and 15 years were 97.4%, 97.4%, 92.8 % and 86.7% respectively. We did not find any risk factor of mortality or of reoperation. The follow-up was completed for all the patients. After a median follow-up time of 5.9 years (range from 0.1 to 15.6 years) 87 patients were in NYHA class I (72.5%), the echographic control showed no or minimal insufficiency in 89 patients (74.2%), mild insufficiency in eight patients (6.7%) and moderate insufficiency in nine patients (7.5%). CONCLUSIONS: Papillary muscle repositioning is a reliable and safe technique, with excellent clinical and echocardiographic long term results. Therefore we propose it as a gold standard to repair anterior leaflet prolapse.