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Chapter 54: Management of Mixed Valvular Heart Disease

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The general rule for treating secondary tricuspid regurgitation (TR) is to optimize therapy for the underlying cause. Which of the following TR outcomes may be observed after correction of underlying mitral or aortic valve disease?

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A. Improvement of TR

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B. Worsening of TR

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C. No change in TR

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D. De novo TR

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E. All of the above

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The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 54) Although it has long been hoped that correction of the hemodynamic load associated with underlying mitral or aortic valve disease would improve secondary TR, observed results remain unpredictable, with TR sometimes improving (option A), sometimes worsening (option B), sometimes remaining unchanged (option C), and sometimes even arising de novo following left-sided valve surgery (option D).1-6 All of the options are thus possible TR outcomes after correction of underlying mitral or aortic valve disease.Therefore the best answer is option E.

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Most TR is secondary to overload caused by left-sided heart disease or by lung disease. Which of the following statements about tricuspid intervention during left-sided surgery is true?

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A. TR surgery reduces postoperative TR but not RV dilatation

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B. TR surgery reduces mortality in this setting

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C. TR surgery reduces the risk of postoperative conduction abnormalities

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D. 10-year survival is similar for mechanical prostheses versus bioprostheses

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E. All of the above

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The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 54) It seems clear that tricuspid intervention during left-sided surgery reduces postoperative TR and RV dilatation (option A is thus not correct). However, it has been difficult to show that TR surgery reduces mortality (option B is thus not correct).5,7-14 Although tricuspid repair reduces postoperative heart failure and TR, it has increased the risk of postoperative conduction abnormalities (option C is thus not correct), requiring permanent pacemaker implantation in some but not all reports. In a large meta-analysis, 10-year survival (about 60%) was nearly identical for bioprostheses versus mechanical prostheses, and this is the correct answer (option D).15

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A 62-year-old man with a history of mitral valve replacement (MVR) 2 years ago presents with increasing leg edema and abdominal girth. A holosystolic murmur is heard at the lower sternal border, with large visible “v” waves noted in the jugular venous pulsation. Echocardiography reveals a normally functioning mitral bioprosthesis, but there is ...

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