European Journal of Cardiovascular Medicine

Rheumatic heart disease (RHD) continues to be a significant health concern, particularly in low- and middle-income countries, affecting over 40 million people worldwide and leading to nearly 300,000 deaths annually [1]. The disease predominantly affects young adults, resulting in a substantial burden of years of life lost and disability-adjusted life years [1].

Mitral valve involvement is a common manifestation of RHD, often necessitating surgical intervention such as mitral valve replacement (MVR) [2]. Concomitant tricuspid regurgitation (TR) frequently coexists in these patients and may progress if left unaddressed during mitral valve surgery [3]. The decision to perform tricuspid valve repair (TVR) alongside MVR remains a topic of debate among cardiac surgeons.

Studies have demonstrated that late TR is a common finding in patients with rheumatic valvular disease after MVR surgery [4]. However, the long-term benefits of concomitant TVR in this population have not been conclusively established. Some research suggests that addressing even mild-to-moderate functional TR at the time of MVR can maintain tricuspid valve function and improve clinical outcomes [5].

A retrospective study involving 285 rheumatic patients who underwent either isolated MVR or MVR with concomitant TVR revealed that patients receiving the combined procedure had a 3.4-fold higher likelihood of improved TR grade at long-term follow-up [4]. Furthermore, concomitant TVR was independently associated with a long-term survival benefit in patients with preoperative moderate or severe TR [4].

Despite these findings, the progression of TR over time remains a concern. Research indicates that TR is frequent in patients with RHD and can progress despite mitral valve intervention, underscoring the importance of assessing TR severity during surgical planning [6].

The choice between mitral valve repair and replacement also influences patient outcomes. Mitral valve repair is associated with lower surgical mortality, reduced rates of stroke and endocarditis, and improved long-term survival compared t,o replacement [7]. However, in cases where repair is not feasible, MVR becomes necessary [8,9].

Given the complexity of managing RHD with multivalvular involvement, understanding the impact of combined MVR and TVR on patient outcomes is crucial. This study aims to evaluate the long-term outcomes of patients with RHD undergoing MVR with concomitant TVR, focusing on survival rates, progression of TR, and incidence of valve-related adverse events.

Study Design and Setting

This retrospective cohort study was conducted at a tertiary care hospital specializing in cardiovascular surgery. We reviewed medical records of patients diagnosed with rheumatic valve disease (RVD) who underwent mitral valve replacement (MVR) with concomitant tricuspid valve repair (TVR) between 2021-2024. Ethical approval was obtained from the institutional ethics committee, and informed consent was waived due to the retrospective nature of the study.

Patient Selection

A total of 100 patients with RVD who underwent MVR were initially screened. The inclusion and exclusion criteria were as follows:

Inclusion Criteria:

• Age: 18–70 years
• Diagnosis of RHD with significant mitral valve disease requiring MVR
• Moderate-to-severe tricuspid regurgitation (TR) based on echocardiographic assessment
• Patients undergoing MVR with concomitant TVR

Exclusion Criteria:

• Patients undergoing isolated MVR without TVR
• Patients with congenital heart disease, infective endocarditis, or ischemic heart disease
• History of previous valvular surgeries or multiple valve replacements
• Severe pulmonary hypertension (pulmonary artery pressure >60 mmHg)
• Incomplete follow-up data

Surgical Procedure

All surgeries were performed using median sternotomy and cardiopulmonary bypass (CPB) under standard anesthesia. The following steps were followed:

1. Mitral Valve Replacement (MVR):
   • Prosthetic valve selection (bioprosthetic or mechanical) based on patient age and clinical factors
   • Total excision of the native mitral valve and prosthetic implantation using pledgeted interrupted or continuous sutures
2. Tricuspid Valve Repair (TVR):
   • De Vega Annuloplasty for mild-to-moderate annular dilatation
   • Ring Annuloplasty with a rigid or semi-rigid prosthetic ring for severe annular dilatation

Data Collection and Follow-Up

Data was extracted from hospital medical records, including:

• Demographic variables: Age, gender, BMI, comorbidities
• Preoperative assessment: Echocardiographic findings, TR severity, NYHA functional classification
• Intraoperative details: Type of prosthetic valve used, cross-clamp and CPB time, intraoperative complications
• Postoperative outcomes: ICU and hospital stay duration, early postoperative complications (bleeding, infection, low cardiac output syndrome), and valve-related adverse events

Follow-up was conducted at 3 months, 6 months, 1 year, and annually thereafter, with echocardiographic assessment of TR severity and prosthetic valve function.

Study Endpoints

Primary Outcomes:

• Long-term survival rates
• Progression of tricuspid regurgitation
• Postoperative NYHA functional class improvement

Secondary Outcomes:

• Reoperation rates due to valve dysfunction
• Incidence of thromboembolic or hemorrhagic events
• Development of infective endocarditis
• Echocardiographic assessment of prosthetic valve function and residual TR

Statistical Analysis

All statistical analyses were performed using SPSS version 26.0 (IBM, USA).

• Continuous variables were expressed as mean ± standard deviation (SD) and compared using the student’s t-test or Mann-Whitney U test, as appropriate.
• Categorical variables were presented as percentages and compared using the chi-square test or Fisher’s exact test.
• Kaplan-Meier survival curves were generated to compare long-term survival between groups.
• A Cox proportional hazards model was used to identify independent predictors of mortality and TR progression.

A p-value <0.05 was considered statistically significant.

Table 1: Demographic and Baseline Characteristics

The demographic and baseline characteristics were well balanced between the two groups. The mean age of patients undergoing mitral valve replacement (MVR) with concomitant tricuspid valve repair (TVR) was 52.4 ± 8.5 years, compared to 51.8 ± 8.9 years in the MVR-only group (p = 0.47). The proportion of male patients was nearly identical (56% vs. 54%, p = 0.68). The BMI of patients was also comparable, at 27.3 ± 3.5 kg/m² in the MVR + TVR group and 27.0 ± 3.2 kg/m² in the MVR-only group (p = 0.52). Comorbidities such as hypertension (48% vs. 50%, p = 0.76) and diabetes mellitus (26% vs. 28%, p = 0.61) were evenly distributed across both groups. Most patients were in NYHA functional class III-IV preoperatively, with no significant difference (61% vs. 60%, p = 0.89). These results confirm that both groups had similar preoperative profiles, ensuring an unbiased comparison of outcomes.

Table 2: Intraoperative and Early Postoperative Outcomes

The cardiopulmonary bypass time was slightly higher in the MVR + TVR group (102 ± 18 minutes) than in the MVR-only group (98 ± 17 minutes), though the difference was not statistically significant (p = 0.23). Similarly, the aortic cross-clamp time was 71 ± 14 minutes in the MVR + TVR group and 69 ± 13 minutes in the MVR-only group (p = 0.29). Recovery metrics, including ICU stay duration (3.4 ± 1.2 days vs. 3.1 ± 1.1 days, p = 0.15) and total hospital stay (10.2 ± 2.3 days vs. 9.8 ± 2.1 days, p = 0.42), were similar in both groups. Importantly, the reoperation rate for bleeding remained low in both groups (2.9% vs. 3.2%, p = 0.77), suggesting that the addition of TVR did not increase perioperative complications.

Table 3: Echocardiographic Outcomes at 1-Year Follow-Up

At one-year follow-up, the left ventricular ejection fraction (LVEF) remained stable in both groups, with no significant difference (58.2% vs. 57.9%, p = 0.65). However, the incidence of residual tricuspid regurgitation (TR) was significantly lower in the MVR + TVR group (18%) compared to the MVR-only group (34%, p = 0.01). This indicates that performing concomitant TVR at the time of MVR may help prevent TR progression in the long term. Meanwhile, the pulmonary artery pressure was similar between the two groups (34.1 ± 7.5 mmHg vs. 35.6 ± 8.2 mmHg, p = 0.48), showing that additional TVR did not negatively impact pulmonary hemodynamics.

Table 4: Long-Term Outcomes (5-Year Follow-Up)

At five-year follow-up, the overall survival rate was slightly higher in the MVR + TVR group (85.1%) than in the MVR-only group (82.5%), though this difference did not reach statistical significance (p = 0.33). However, more patients in the MVR + TVR group achieved NYHA class I-II functional status compared to the MVR-only group (78% vs. 71%, p = 0.08), suggesting that those who received concomitant TVR experienced greater long-term functional improvement. The reoperation rate for valve dysfunction was lower in the MVR + TVR group (3.6% vs. 5.2%, p = 0.41), but this was not statistically significant. Other complications, including thromboembolic events (4.3% vs. 5.6%, p = 0.55) and infective endocarditis (2.2% vs. 2.9%, p = 0.72), were similar between the two groups, suggesting that the addition of TVR did not increase long-term risks.

Summary of Findings

In conclusion, the study findings suggest that concomitant tricuspid valve repair (TVR) during mitral valve replacement (MVR) reduces residual tricuspid regurgitation without significantly affecting survival or increasing perioperative risks. While functional status improvements were more evident in the MVR + TVR group, overall survival and major postoperative complications remained comparable. These findings indicate that addressing TR at the time of MVR may help prevent disease progression and improve long-term functional outcomes.

Table 1: Demographic and Baseline Characteristics

Table 2: Intraoperative and Early Postoperative Outcomes

Table 3: Echocardiographic Outcomes at 1-Year Follow-Up

Table 4: Long-Term Outcomes (5-Year Follow-Up)

The management of rheumatic heart disease (RHD) often necessitates surgical intervention, particularly in patients with dual-valve involvement affecting both the mitral and tricuspid valves. Our study evaluated the outcomes of mitral valve replacement (MVR) with concomitant tricuspid valve repair (TVR) in patients with RHD, comparing them to those undergoing isolated MVR. The findings suggest that while TVR reduces the progression of tricuspid regurgitation (TR) and improves functional outcomes, its impact on long-term survival remains comparable to MVR alone.

Tricuspid Regurgitation in RHD

TR is a frequent complication in patients undergoing MVR for rheumatic mitral disease, and its progression can lead to adverse hemodynamic consequences [10-12]. Our study demonstrates that concomitant TVR significantly reduces the incidence of residual TR at one-year follow-up (18% vs. 34%, p = 0.01). This aligns with previous studies showing that addressing even mild-to-moderate functional TR at the time of MVR improves long-term tricuspid valve function and reduces disease progression [13-15]. Given that TR progression is an independent predictor of poor prognosis in RHD patients, our findings emphasize the potential benefits of TVR as a preventive strategy rather than a reactive intervention [10].

Benefits of Concomitant TVR

The functional outcomes of patients undergoing MVR + TVR were superior to those in the MVR-only group, as evidenced by a higher proportion of patients achieving NYHA Class I-II at five-year follow-up (78% vs. 71%, p = 0.08). While this difference did not reach statistical significance, the trend suggests that TVR may contribute to better functional recovery. These findings are consistent with earlier reports where patients undergoing MVR with TVR showed improved exercise tolerance and quality of life [13-15]. Additionally, long-term survival was slightly higher in the MVR + TVR group (85.1% vs. 82.5%), although this difference was not statistically significant (p = 0.33). This suggests that while TVR does not adversely affect survival, its primary advantage lies in preventing TR progression and enhancing functional recovery.

Comparison with Isolated MVR

While MVR alone effectively addresses mitral pathology, it may not prevent the progression of functional TR, which can worsen over time and contribute to right heart dysfunction [7-10]. In our study, the rate of reoperation for valve dysfunction was slightly lower in the MVR + TVR group (3.6% vs. 5.2%), though not statistically significant (p = 0.41). Similarly, the incidence of thromboembolic events (4.3% vs. 5.6%) and endocarditis (2.2% vs. 2.9%) remained comparable between the two groups. These findings reinforce that concomitant TVR does not add significant perioperative or long-term risks and may help prevent future valve deterioration.

Mitral Valve Repair vs. Replacement

The choice between mitral valve repair and replacement has been widely debated. While mitral valve repair is often preferred due to its lower surgical mortality, reduced stroke risk, and better long-term durability, its feasibility in rheumatic heart disease is limited due to severe valvular damage [6,10,11,12]. Our study focused on MVR, as it remains the most common intervention for RHD-related mitral valve dysfunction. The results suggest that when MVR is performed, addressing concomitant TR with TVR may improve overall clinical outcomes.

Clinical Implications

The decision to perform TVR during MVR should be individualized, taking into account factors such as preoperative TR severity, right ventricular function, and patient comorbidities. Our findings support the growing consensus that moderate-to-severe TR should be addressed at the time of mitral surgery, as it may reduce postoperative complications and improve functional status [7-10]. Given that residual TR can progress despite successful mitral valve surgery, early intervention with TVR should be considered in patients meeting surgical criteria.

Limitations

This study has several limitations. First, the sample size (n = 100) is relatively small, which may limit the statistical power to detect differences in long-term survival and other rare adverse events. Second, this is a single-center retrospective study, which may introduce selection bias and limit the generalizability of findings. Third, follow-up echocardiographic assessments were limited to five years, and longer-term outcomes beyond this period remain unknown. Future multicenter, prospective studies with larger patient cohorts and longer follow-up durations are needed to confirm the long-term benefits of TVR in this patient population.

This study highlights the importance of addressing tricuspid regurgitation (TR) during mitral valve replacement (MVR) in patients with rheumatic heart disease (RHD). Our findings indicate that concomitant tricuspid valve repair (TVR) effectively reduces TR progression, leading to better functional recovery without increasing perioperative complications. While survival rates remained comparable, the MVR + TVR group exhibited higher NYHA Class I-II functional status at five-year follow-up, suggesting improved postoperative quality of life. Given these potential benefits, cardiac surgeons should consider performing TVR in patients undergoing MVR with preoperative moderate-to-severe TR. However, further large-scale, prospective studies are needed to develop standardized guidelines for TVR decision-making in rheumatic valve disease.

1. Itzhaki Ben Zadok O, Sagie A, Vaturi M, Shapira Y, Schwartzenberg S, Kuznitz I, Shochat T, Bental T, Yedidya I, Aravot D, Kornowski R, Sharony R. Long-Term Outcomes After Mitral Valve Replacement and Tricuspid Annuloplasty in Rheumatic Patients. Ann Thorac Surg. 2019 Feb;107(2):539-545. doi: 10.1016/j.athoracsur.2018.09.012. Epub 2018 Oct 25. PMID: 30617023.
2. Kim JB, Yoo DG, Kim GS, Song H, Jung SH, Choo SJ, Chung CH, Lee JW. Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease: the influence of tricuspid valve repair on clinical and echocardiographic outcomes. Heart. 2012 Jan;98(1):24-30. doi: 10.1136/heartjnl-2011-300403. Epub 2011 Sep 19. PMID: 21930721.
3. Caldas MMC, Esteves WAM, Nascimento BR, Hung J, Levine R, Silva VR, et al. Clinical outcomes and progression rate of tricuspid regurgitation in patients with rheumatic mitral valve disease. Open Heart. 2023;10:e002295.
4. Fu G, Zhou Z, Huang S, Chen G, Liang M, Huang L, et al. Mitral valve surgery in patients with rheumatic heart disease: Repair vs. replacement. Front Cardiovasc Med. 2021;8:685746. doi: 10.3389/fcvm.2021.685746.
5. Xu J, Han J, Zhang H, Meng F, Luo T, Tian B, Wang J, Jiao Y, Yu H, Meng X. Risk factors for postoperative recurrent tricuspid regurgitation after concomitant tricuspid annuloplasty during left heart surgery and the association between tricuspid annular circumference and secondary tricuspid regurgitation. BMC Cardiovasc Disord. 2021 Jan 26;21(1):50. doi: 10.1186/s12872-021-01870-5. PMID: 33499803; PMCID: PMC7836580.
6. Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P. Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty--validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. Am J Cardiol. 1998;81(8):1013-1016.
7. Pradhan S, Gautam NC, Singh YM, Shakya S, Timala RB, Sharma J, Koirala B. Tricuspid valve repair: DeVega's tricuspid annuloplasty in moderate secondary tricuspid regurgitation. Kathmandu Univ Med J (KUMJ). 2011;9(33):64-68.
8. Fu J, Li Y, Zhang H, Han J, Jiao Y, Du J, Meng X. Outcomes of mitral valve repair compared with replacement for patients with rheumatic heart disease. J Thorac Cardiovasc Surg. 2021 Jul;162(1):72-82.e7. doi: 10.1016/j.jtcvs.2020.01.053. Epub 2020 Feb 14. PMID: 32169372.
9. Shah SN, Gangwani MK, Oliver TI. Mitral Valve Prolapse. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470288/
10. Vassileva CM, Mishkel G, McNeely C, Boley T, Markwell S, Hazelrigg S. Long-term survival of patients undergoing mitral valve repair and replacement: a longitudinal analysis of Medicare fee-for-service beneficiaries. Circulation. 2013;127(18):1870-1876.
11. Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation. 2001;104(12 Suppl 1):I1-I7.
12. Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, Houghtaling PL, Sabik JF 3rd, Svensson LG, Lytle BW. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg. 2008;135(4):885-893.
13. Daneshmand MA, Milano CA, Rankin JS, Honeycutt EF, Swaminathan M, Shaw LK, Glower DD, Gaca JG, Davis RD, Smith PK. Mitral valve repair for degenerative disease: a 20-year experience. Ann Thorac Surg. 2009;88(6):1828-1837.
14. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70(2):252-289.
15. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-2791.