Suture bicuspidization repair for mild or moderate tricuspid regurgitation at the time of mitral valve surgery: success or bust?

Tricuspid regurgitation (TR) is a common pathology that is often present at the time of mitral valve surgery. The decision, however, to intervene on moderate or less TR with annular dilatation is not widely utilized or well supported due to the lack of convincing contemporary evidence. We read with great interest the paper by Piperata et al. in this issue of the journal. Piperata et al. [1] report on their single-centre long-term outcomes of concomitant suture bicuspidization tricuspid valve repair of mild to moderate TR at the time of mitral valve surgery. In their propensity-matched, retrospective analyses, the authors demonstrated that suture bicuspidization was a safe and durable strategy in terms of comparable intensive care and hospital length of stay, permanent pacemaker implantation rates, and 30-day mortality although the cross-clamp and cardiopulmonary bypass times were significantly longer [1]. Furthermore, after a median follow-up of 6 years, concomitant mitral valve surgery with tricuspid valve did not appear to be associated with increased mortality risk and was without a survival penalty at 10 years. The authors, first of all, are to be congratulated on their outstanding results as well as for their systematic conduct of this timely study. The paradigm in the management of TR is shifting towards more aggressive approaches as reflected in current clinical guidelines [2–4]. The tricuspid valve, which was previously perceived as the forgotten valve, is no longer the forgotten valve as emerging evidence demonstrates the long-term impact of TR progression on overall patient outcomes [2–5]. However, there is still controversy surrounding the optimal management of less than severe TR, and this study further provides food for thought as we tailor nuanced care for patients with concomitant less than moderate TR at the time of mitral valve surgery. Historically, previous reliance on mitral valve surgery to improve moderate or less functional TR, and overestimation of the clinical tolerance for right-sided pathology, led to conservative approaches for TR [5, 6]. Tricuspid valve repair of less than severe disease with annular dilatation has shown excellent outcomes in the context of reduced progression to severe TR and improved right ventricular function, with the possible downside of increased permanent pacemaker implantation rates [5, 6]. While the later concern is extremely crucial, an important finding Piperata et al. [1] showed that the suture bicuspidization technique for mild to moderate TR at the time of mitral valve surgery was not associated with an increased pacemaker implantation rates, a complication with significant possible clinical sequelae. Again, Piperata et al. are to be commended for reporting promising outcomes for concomitant aggressive intervention on mild to moderate TR, which further underscores the long-term benefits of earlier treatment strategies. However, given the nuanced nature of existing treatment options in this unique patient population, the results of this important study should be interpreted carefully within the context of clinical decision-making. First, it should be noted that not all tricuspid repair techniques offer equivalent safety and durability outcomes. An unfortunate blind spot in this study is the lack of sufficient comparisons across the various tricuspid repair strategies. When compared head-to-head, suture annuloplasty techniques have been shown to underperform against ring annuloplasty especially in terms of lower TR event-free survival, greater progression to severe disease, and increased rates of reoperation [5, 7]. Suture bicuspidization Alone, as observed in the mitral valve landscape, may not address the underlying aetiology of functional TR due to the lack of annular stabilization [5]. Granted, Piperata et al. showed durable reduced tricuspid valve annulus diameter, and this could be potentially due to earlier intervention prior to significant downstream impact on the right ventricle. Thus, to provide clinical equipoise in light of this hypothesis-generating study, a randomized comparison of suture bicuspidization to ring annuloplasty to manage mild to moderate TR at the time of mitral valve surgery may be necessary next step. Conflict of interest: none declared.

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