Predictors of rheumatic tricuspid involvement and concomitant tricuspid valve balloon dilation (TVBD) during balloon mitral valvotomy in rheumatic mitral stenosis -The PREToRIuS study

摘要

Background: Tricuspid valve disease frequently accompaniesrheumatic mitral valve disease.Organic tricuspid valve diseasewith concomitant TS and TR is also frequent, and uncorrectedsevere TR has been associated with adverse outcomes of bothBMV and surgical mitral valve reconstruction/replacement.Methods: We retrospectively analysed patients in our hospitalwho serially underwent concomitant balloon dilation of tricuspidvalve along with BMV and sought to determine predictors ofconcomitant tricuspid valve disease requiring tricuspid valveintervention, and clinical characteristics of patients undergoingthe same.Of the 12005 patients who underwent BMV at ourinstitute,10916 (91%) had some affection of tricuspid valve ,with4716 (38.3%)found to have at least moderate TR or more.26 patients(0.21%)have undergone simultaneous TVBD, with 3 patientshaving undergone the procedures twice. The decision to performTVBD during BMV was made according to trans-tricuspid gradientmeasured as continuous wave signal across the “doming“tricuspid valve , and difference of RVedp and RA mean pressuresby post BMV cath.The same Accura balloon that was used for BMVwas used for the TVBD( sizes 24,26,28) by withdrawing it acrossthe tricuspid valve.The balloon was dilated under fluoro guidancetill the waist of the stenosis across TV disappeared. Between serialdilations, echo guidance was taken to assess result of previousdilation.Results: Patients undergoing BMV who underwent concomitanttricuspid balloon dilation( Group A) for rheumatic TS were morelikely to be female (n?21 of 26 patients( p< 0.001)),older(mean age:30.5+/- 4.5 years ), more likely to present with right-sided symptoms, more likely have undergone a past valve procedure( eitherBMV/CMV,n?12) and have longer duration of disease( meanduration: 11.4 +/-4.4 years,p< 0.001) than Group B patients.14 patientsof the 26 ( group A) had AF (p<0.001) and were on oralanticoagulation. Concomitant mitral involvement was seen 100%patients, and moderately advanced aortic valve disease (moderateAR, mild to moderate AS) also was significantly more in group Apatients.Pre-BMV trans-mitral gradients (due to the upstream TS,however were not statistically significantly different betweengroups A and B. The post procedural outcomes of the BMV withTVBD in group A also did not reach significantly different valuesas compared to those who underwent BMV alone. Though asatisfactory initial result of TVBD was obtained in all patients,most patients were referred for combined surgery in futuredue to advanced disease with mitral, aortic and tricuspidinvolvement.Conclusions: Concomitant tricuspid involvement can be considereda frequent accompaniment of advanced rheumatic mitraldisease, and concomitant TVBD during BMV can be safe andefficacious procedure with good immediate benefits but needingmitral and tricuspid valve surgery in future. Higher patient age,presence of AF and concomitant aortic disease probably arepointers towards advanced age of disease in these patients.