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Nardi et al. Vessel Plus 2018;2:4 I http://dx.doi.org/10.20517/2574-1209.2017.35 Page 3 of 6

with mitral valve surgery (85%). Tricuspid valve repair was done by the use of De Vega or ring annuloplasty.
Operative mortality was 14%, 15-year survival 34%. Risk factors for late mortality included the preoperative
severity > 3+ of the FTR, whereas tricuspid valve surgery concomitantly performed with mitral and/or aortic
surgery was not a predictive factor for increased mortality . Chan et al. studied 624 mitral valve replacement
[16]
[17]
patients. They performed in 125 out of 231 patients having preoperatively a FTR > 2+ tricuspid repair using
De Vega or ring annuloplasty techniques. During a mean follow-up of 6.8 years among patients who had
preoperative FTR > 2+, the regurgitation worsened in 10 (8%) patients who received repair compared with 85
(17%) who did not. Moreover, the progression of FTR was less developed in the repair group (P = 0.008) .
[17]
[18]
Navia et al. have compared the effectiveness of several tricuspid valve repair techniques in 2277 patients
who had undergone left-sided valve surgery. At 10 years of follow-up, the use of a rigid prosthetic ring
[18]
provided the most sustained reduction of FTR .
On the other hand, Yilmaz et al. in a series of 699 patients undergoing mitral valve repair, showed that at
[19]
3 years of follow-up, a clinically silent non-severe FTR was unlikely to progress. Huang et al. in a series of
[20]
448 patients undergoing tricuspid annuloplasty with concomitant procedures, evaluated the results of the
De Vega (216 patients) or ring (232 patients) annuloplasty. The indication to FTR treatment was done on the
symptomatic tricuspid regurgitation grade (4+) (91.3%) or in presence of moderate FTR (< 4+) or marked
tricuspid annular dilatation (diameter > 4.0 cm) (8.7%). With both types of tricuspid valve repair techniques
postoperative echocardiography showed significant improvement of the FTR grade (from 3.4 preoperatively
to 0.6, P < 0.05); 5-year freedom from reoperation (81% vs. 75%, P = 0.124) was similar. They concluded
that the De Vega annuloplasty is an acceptable strategy, improving both clinical and echocardiographic
status of the patients during long-term follow-up, although the event-free survival appeared to be lower in
[20]
comparison with that observed for the ring annuloplasty (74.5% vs. 78.8%, P = NS) .
[21]
Finally, Takano et al. in a smaller series of 71 patients undergoing mitral valve replacement and tricuspid
valve repair, but with a follow-up period of 20 years, identified the preoperative moderate grade of FTR as a
significant risk factor for the development of late severe tricuspid regurgitation. They claimed that an aggressive
early treatment of FTR at the time of mitral valve surgery may prevent the late progression of the FTR.

In our recent experience, from January 2015 to October 2017, on a series of 156 patients treated for left-sided
heart valve disease (mitral, mitral and aortic valve disease), 57 patients (36.5%) underwent suture annuloplasty
techniques (De Vega, 49 patients; Kay, 8 patients). In the mitral surgery group of patients (n = 114), FTR was
treated in 35 cases (30.7%). Indication for the surgical treatment was given in the presence of symptomatic
severe or moderate FTR, or when the diameter of the tricuspid valve annulus reached 40 mm, regardless of
symptoms [22,23] . We have adopted those tricuspid valve repair techniques because they require less surgical time
in comparison with the use of a ring implant. The increased incidence of the surgical treatment of FTR observed
in our series is in accordance with that reported in the database of the Society of Thoracic Surgeons. The trend
of the tricuspid valve surgery increased with the time: 11,405 patients treated in the first period of analysis
(2000-2003), 21,804 and 21,166 in the last periods (2004-2007 and 2008-2010). In this report operative mortality
declined from 10.6% in 2000 to 8.2% in 2010 (P < 0.001) .
[24]

In our series the operative mortality for mitral valve repair (29 patients) and mitral plus tricuspid valve
repair (9 patients) was similar (0% vs. 0%), as well as that observed for mitral valve replacement (50 patients)
and mitral valve replacement plus tricuspid valve repair (26 patients) (2% vs. 3.6%, P = NS).

As compared to preoperative period, clinical status of patients surgically treated for FTR during the short-
term follow-up showed a significant improvement in NYHA class (3.0 ± 0.7 preoperatively vs. 1.4 ± 0.6
at follow-up), pulmonary artery pressure mean value (60 ± 22 vs. 32 ± 10 mmHg), mean value of FTR (2.8 ±
1.0/4+ vs. 0.7 ± 0.6/4+) (P < 0.001, for all comparisons). None of the patients required permanent pacemaker