Long-term results (up to 14 years) of the clover technique for the treatment of complex tricuspid valve regurgitation.
OBJECTIVE
To report the long-term results of the clover technique for the treatment of complex forms of tricuspid regurgitation (TR).


METHODS
Ninety-six consecutive patients (mean age 60 ± 16.4, left ventricular ejection fraction 58 ± 8.8%) with severe or moderately-severe TR due to important leaflets prolapse/flail (81 patients), tethering (13 patients) or mixed (2 patients) lesions underwent clover repair combined with annuloplasty. The aetiology of TR was degenerative in 74 cases (77.1%), post-traumatic in 9 (9.4%) and secondary to dilated cardiomyopathy in 13 (13.5%). All patients but 3 (96.8%) underwent ring (59 patients, 61.5%) or suture (34 patients, 35.4%) annuloplasty. Concomitant procedures (mainly mitral surgery) were performed in 82 patients (85.4%).


RESULTS
Hospital mortality was 7.2%. At hospital discharge 92 (95.8%) patients had no or mild TR. Follow-up was 98% complete (median 9 years, interquartile range 5.1; 10.9). At 12 years the overall survival was 71.6 ± 7.22% and the cumulative incidence function of cardiac death with non-cardiac death as competing risk 16 ± 4.1% [95% confidence interval (95% CI) 9.5-25.7]. At 12 years the cumulative incidence function of TR ≥ 3+ and TR ≥ 2+ with death as competing risk were 1.2 ± 1.2% (95% CI 0.1-5.8) and 28 ± 7.7% (95% CI 14.3-43.5), respectively. Preoperative left ventricular ejection fraction (hazard ratio 0.9, CI 0.9-1, P  = 0.05) and previous cardiac surgery (hazard ratio 2.7, 95% CI 1-7.1, P  = 0.03) were predictors of recurrent TR ≥ 2+ at univariable but not at multivariable analysis.


CONCLUSIONS
Complex forms of TR due to severe prolapse or tethering of the leaflets can be effectively treated with the clover technique with very satisfactory long-term results and extremely low recurrence of severe TR.
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Michele
M
De Bonis
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Elisabetta
E
Lapenna
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Stefania
S
Di Sanzo
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Benedetto
B
Del Forno
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy.
Federico
F
Pappalardo
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Alessandro
A
Castiglioni
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Luca
L
Vicentini
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Alberto
A
Pozzoli
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Ilaria
I
Giambuzzi
Interventional Cadiology Unit, IRCCS San Raffaele Hospital, Milan, Italy.
Azeem
A
Latib
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Davide
D
Schiavi
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Giovanni
G
La Canna
Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Ottavio
O
Alfieri
D058385:Cardiac Valve Annuloplasty / Q000379:methods*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D014262:Tricuspid Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016277:Ventricular Function, Left / Q000502:physiology
Tricuspid prolapse; Tricuspid regurgitation; Valve repair