Tricuspid regurgitation (TR) is common among patients undergoing surgery for degenerative mitral regurgitation (DMR) and is associated with adverse outcomes. The role of concomitant tricuspid annuloplasty (TA) during mitral valve repair (MVr) remains controversial. To address this, we performed a systematic review and meta-analysis of randomized and observational studies published up to November 2024, comparing isolated MVr versus MVr with concomitant TA in patients with DMR (CRD42024627505). Reconstructed Kaplan–Meier time-to-event data were analyzed using Cox frailty models to evaluate survival, TR progression, and permanent pacemaker (PPM) implantation. Sensitivity analyses included randomized or propensity-matched cohorts. A total of 5 studies, including 3,123 patients, were analyzed. Early (1-year) and long-term (up to 15 years) survival were comparable between isolated MVr and concomitant TA (97.3% vs. 96.9%, HR: 1.25, 95% CI: 0.76 to 2.08, p = 0.381 and 72.2% vs 79.7%, HR: 1.28, 95% CI: 0.96 to 1.72, p = 0.092, respectively). Concomitant TA significantly reduced the risk of ≥moderate TR progression (HR: 0.34, 95% CI: 0.17 to 0.70, p = 0.003). However, PPM implantation was higher with TA during the perioperative period (7.4% vs 1.1%, HR 5.76, 95% CI 3.13 to 10.59) and remained elevated at 2 years. Sensitivity analyses confirmed these findings. In conclusion, in patients undergoing MVr for DMR, concomitant TA effectively prevents TR progression without compromising survival but is associated with increased PPM implantation. These results support a selective, guideline-directed approach to TA based on patient- and disease-specific risk factors.
Introduction
Tricuspid regurgitation (TR) is frequently observed among patients undergoing surgery for degenerative mitral regurgitation (DMR) and has been increasingly recognized as an adverse prognostic marker, even when mild or moderate in severity. Historically, TR was often left untreated at the time of mitral valve repair (MVr) under the assumption that correction of left-sided pathology would lead to regression of right-sided dysfunction. However, subsequent studies have shown that up to 50% of patients experience subsequent TR progression, which is associated with right heart failure, poorer functional status, and increased mortality. Reoperation for severe TR carries prohibitive perioperative risk, underscoring the importance of optimizing management during the index procedure.
Guidelines now recommend concomitant tricuspid annuloplasty (TA) for severe TR and suggest its consideration in patients with annular dilation, atrial fibrillation, or pulmonary hypertension, even when TR is mild or moderate. , Evidence from observational studies and a Cardiothoracic Surgical Trials Network (CTSN) randomized trial indicates that TA reduces TR progression and promotes right ventricular reverse remodeling but at the cost of longer operative times and a markedly increased risk of permanent pacemaker (PPM) implantation. As a result, the management of concomitant tricuspid repair remains controversial, with substantial variation in clinical practice.
To clarify the balance of benefit and risk, we conducted a systematic review and meta-analysis of randomized and observational studies comparing concomitant TA versus isolated MVr in patients with DMR. Our objective was to evaluate the effect of TA on survival, TR progression, and PPM implantation across early and long-term follow-up.
Methods
Search strategy
This systematic review and meta-analysis was performed in adherence to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines ( Supplementary Table 1 ). The study protocol was prospectively registered (CRD42024627505). Ethical approval was not required for this study-level meta-analysis.
A systematic search of electronic databases was conducted to identify randomized controlled trials and observational studies published up to November 2024. The search strategy was structured using the PICO framework, with the research question formulated as follows: “(P): Among patients with DMR, (I): does the addition of TA during MVr, (C): compared to MVr alone, (O): result in improved outcomes, including survival rates, TR, and the frequency of permanent pacemaker implantation?” The exact search strategy is detailed in Supplementary Table 2 . Reference lists of eligible studies and meta-analyses were also reviewed. Two authors (X.J., M.P.S.) independently assessed titles, abstracts, and full-texts for eligibility using standardized in- and exclusion criteria. Inclusion criteria were as follows: (1) patients with DMR undergoing MVr, (2) patients who underwent either concomitant TA or no tricuspid valve procedure, and (3) studies must provide Kaplan-Meier curves for individual outcomes. Exclusion criteria included patients undergoing concomitant aortic valve intervention, mitral valve replacement, or alternative tricuspid valve repairs such as suture bicuspidization or tricuspid valve replacement. Further exclusion criteria consisted of reviews, meta-analyses, case reports/series, one-arm studies, or studies with overlapping samples.
Data extraction, quality assessment and statistical analysis
Patient characteristics and Kaplan-Meier curves were extracted independently by 2 reviewers (X.J, M.P.S.). The methodological quality and risk of bias were also assessed independently by the same authors (X.J, M.P.S.) using the Cochrane Risk of Bias tool.
Kaplan–Meier curves were digitized using Web Plot Digitizer software. Reconstructed time-to-event data and individual patient data (IPD) were derived from the digitized Kaplan–Meier plots, along with the corresponding total number of patients, total events, and the number of patients at risk at various time intervals for each study arm. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using a Cox frailty model with robust standard errors. Heterogeneity across studies was assessed by testing for an interaction between the study and treatment effect, incorporating a γ frailty term to account for between-study variability, with studies modeled as random effects ( Supplementary Table 3 ). The significance of the variance parameter was evaluated using the likelihood ratio test. Fixed effects were included for the respective arms, and proportional hazards were checked using the Grambsch–Therneau test and Schoenfeld residual diagnostic plots (all analysis demonstrated proportional hazards). Sensitivity analyses were conducted for all outcomes in randomized or matched studies using propensity score matching (PSM) or inverse probability of treatment weighting (IPTW). Significance testing was performed at the 2-tailed 5% significance level. All analyses were completed with R Statistical Software (version 4.4.0, Foundation for Statistical Computing, Vienna, Austria).
Results
Study selection
Our initial search yielded 466 unique citations ( Figure 1 ), of which 16 publications were potentially relevant. Among these, 5 fulfilled our eligibility criteria. ,,,, Characteristics of each study and their participants are shown in Tables 1 and 2 . The 5 included studies comprised a total of 3,123 patients. One study was a randomized controlled trial, whereas the other studies had a retrospective observational design. All studies used some form of adjustment for residual confounding. Supplementary Figure 1 shows the qualitative assessment of the studies with the RoB 2 and ROBINS-I tool. There are several concerns regarding confounding factors and missing data.
Study flowchart.
Table 1
Characteristics of the studies comparing mitral valve repair with or without concomitant tricuspid annuloplasty.
| Study | Study design | Period | Total sample– n | MVr– n | MVr + TA– n | Indication for TA | Adjustment for possible confounders and or multivariable analysis |
|---|---|---|---|---|---|---|---|
| Chikwe et al | Retrospective observational | 2003–2001 | 645 | 226 | 419 | Moderate TR, TAd (≥40 mm), or size mismatch between leaflet and annulus on direct inspection. | Multivariable analysis correcting for age, comorbidities, and echocardiography. |
| Dreyfus et al | Retrospective observational | 2005–2015 | 441 | 207 | 234 | Concomitant severe FTR, or TAd enlargement ≥40 mm. | Multivariable analysis correcting for age, sex, DMR, and FTR severity. |
| Lee et al | Retrospective observational | 1997–2013 | 151 | 66 | 85 | Atrial fibrillation, mild FTR, and, TAd (≥40 mm or >21 mm/m 2). |
IPTW-adjusted analysis
and PS matching. |
| Gammie et al | Randomized controlled trial | 2016–2018 | 401 | 203 | 198 | Moderate TR, or mild TR with TAd (≥40 mm or >21 mm/m 2). | NA |
| Brescia et al | Retrospective observational | 2011–2021 | 1485 | 1068 | 417 | Concomitant severe TR, or TAd enlargement ≥40 with mild-to-moderate TR. | Multivariable regression incorporating pre and intraoperative risk factors. |
Study design, time period, total sample size, number of patients in each treatment group, indications for TA, and statistical adjustments for potential confounders are reported.
MVr = mitral valve repair; TA = tricuspid annuloplasty; TAd = tricuspid annular diameter; FTR = functional tricuspid regurgitation; DMR = degenerative mitral regurgitation; TR = tricuspid regurgitation; IPTW = inverse probability of treatment weighting; PS = propensity score; NA = not applicable.
Table 2
Patient characteristics of the included studies.
| Study | Age, yr | Female, % | AF, % | NYHA III-IV, % | LVEF, % | LAVI, mL/m 2 | TAd, mm | TAdi, mm/m 2 | ≥ Moderate TR, % |
|---|---|---|---|---|---|---|---|---|---|
| Chikwe et al | 52±14/59±12 | 41/34 | 12/23 | NA | 62±7/60±8 | NA | 35±6/39±6 | NA | 0/17 |
| Dreyfus et al | 67±14/65±12 | 68/72 | 23/39 | 36/37 | 66±9/65±10 | 83±34/82±36 | 36±2/43±2 | NA | 10/29 |
| Lee et al | 60±12/57±12 | 61/46 | 20/68 | 27/17 | 64±8/61±7 | 88±39/95±45 | 31±6/35±6 | 19±2/20±3 | NA |
| Gammie et al | 68±10/67±11 | 25/26 | 44/44 | 34/27 | 64±7/64±7 | NA | 42±5/42±5 | NA | 38/37 |
| Brescia et al | 62±13/68±12 | 40/36 | 20/50 | NA | NA | NA | NA | NA | 11/51 |
| Study | Bypass time, min | Crossclamp time, min | Concomitant CABG, % | Maze Procedure, % | |||||
| Chikwe et al | NA | NA | 10/9 | 12/24 | |||||
| Dreyfus et al | 125±50/138±36 | 99±38/113±30 | 18/7 | 10/23 | |||||
| Lee et al | NA | NA | 0/0 | 18/65 | |||||
| Gammie et al | 133±59/166±69 | NA | 11/11 | 24/28 | |||||
| Brescia et al | 93±45/122±56 | 68±33/93±41 | 9/11 | 19/54 * | |||||
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