title: Natural history of coexistent tricuspid regurgitation in patients with degenerative mitral valve disease: implications for future guidelines.
abstract: OBJECTIVE
  The management of coexistent tricuspid regurgitation in patients with mitral regurgitation remains controversial. We sought to define the incidence and natural history of coexistent tricuspid regurgitation in patients undergoing isolated mitral surgery for degenerative mitral regurgitation, as well as the effect of late secondary tricuspid regurgitation on cardiovascular symptom burden and survival.
  
  
  METHODS
  To minimize confounding, analysis was limited to 495 consecutive patients who underwent isolated mitral surgery for degenerative mitral valve disease between 2002 and 2011. Patients with coexistent severe tricuspid regurgitation were excluded because such patients typically undergo concomitant tricuspid intervention.
  
  
  RESULTS
  Grade 1 to 3 coexistent tricuspid regurgitation was present in 215 patients (43%) preoperatively. Actuarial freedom from grade 3 to 4 tricuspid regurgitation 1, 5, and 9 years after surgery was 100% ± 0%, 90% ± 2%, and 64% ± 7%, respectively. Older age (P < .001) and grade of preoperative tricuspid regurgitation (P = .006) independently predicted postoperative progression of tricuspid regurgitation on multivariable analysis. However, when limited to patients with mild or absent tricuspid regurgitation, indexed tricuspid annular diameter was the only significant risk factor for late tricuspid regurgitation (P = .04). New York Heart Association functional class and long-term survival did not worsen with development of late secondary tricuspid regurgitation (P = .4 and P = .6, respectively). However, right ventricular dysfunction was significantly more common in patients with more severe late tricuspid regurgitation (P = .007).
  
  
  CONCLUSIONS
  Despite durable correction of degenerative mitral regurgitation, less than severe tricuspid regurgitation is likely to progress after surgery if uncorrected. Given the low incremental risk of tricuspid annuloplasty, a more aggressive strategy of concomitant tricuspid repair may be warranted.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Goldstone
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Howard
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
authors.forename: John W
authors.initials: JW
authors.lastname: MacArthur
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Pavan
authors.initials: P
authors.lastname: Atluri
authors.affiliation: Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
authors.forename: James N
authors.initials: JN
authors.lastname: Kirkpatrick
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif. Electronic address: joswoo@stanford.edu.
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
mesh_terms: D000367:Age Factors; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000592:standards*; D018450:Disease Progression; D005260:Female; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D015999:Multivariate Analysis; D010414:Pennsylvania / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014262:Tricuspid Valve Insufficiency / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology; D018497:Ventricular Dysfunction, Right / Q000453:epidemiology / Q000503:physiopathology; D016278:Ventricular Function, Right