MITRAL VALVE REPLACEMENT WITH AND WITHOUT CONCOMITANT TRICUSPID VALVE REPAIR USING MODIFIED DE VEGA ANNULOPLASTY IN RHEUMATIC HEART DISEASE: A PROSPECTIVE STUDY FROM KASHMIR

Rheumatic heart disease remains a significant global health burden, particularly affecting populations in developing countries where it continues to be a leading cause of cardiovascular morbidity and mortality. The chronic inflammatory process characteristic of rheumatic heart disease frequently involves multiple cardiac valves, with mitral valve pathology being the most prevalent manifestation A. M. A. Elfeky et al., 2020. The progressive nature of rheumatic mitral valve disease often necessitates surgical intervention, with mitral valve replacement being the predominant therapeutic approach when valve repair is not feasible due to extensive cicatrization and subvalvular apparatus involvement A. M. A. Elfeky et al., 2020.

A critical clinical challenge in the surgical management of rheumatic mitral valve disease is the frequent coexistence of functional tricuspid regurgitation. O. Farooq et al., 2021 demonstrated that mitral valve abnormalities in rheumatic heart disease commonly lead to functional tricuspid regurgitation, creating a complex surgical decision-making scenario. The pathophysiological mechanism underlying this association involves elevated left atrial pressures secondary to mitral valve dysfunction, which subsequently increases pulmonary vascular resistance and right heart pressures, ultimately resulting in tricuspid annular dilatation and functional regurgitation S. Pradhan et al., 2012.

The management of concomitant moderate tricuspid regurgitation during mitral valve replacement surgery remains a subject of considerable debate in contemporary cardiac surgery. A. Dokhan et al., 2015 highlighted that moderate tricuspid regurgitation exhibits variable natural history, as it may either regress spontaneously following mitral valve surgery or progress to severe regurgitation over time. This uncertainty has generated ongoing controversy regarding the optimal surgical approach, with some advocating for concurrent tricuspid valve repair while others support a more conservative strategy of addressing only the mitral valve pathology.

The De Vega annuloplasty technique, first described in the 1970s, has emerged as a widely adopted surgical approach for functional tricuspid regurgitation repair. S. Pradhan et al., 2012 demonstrated that De Vega tricuspid annuloplasty confers superior repair results compared to mitral valve replacement alone in patients with moderate tricuspid regurgitation. Subsequently, modifications to the original De Vega technique have been developed to enhance durability and clinical outcomes. Anbukumar Palanisamy et al., 2022 compared traditional De Vega annuloplasty with a modified technique utilizing polytetrafluoroethylene bands, demonstrating improved outcomes with the modified approach, with 76% of patients achieving mild tricuspid regurgitation compared to 56% with the conventional technique.

Recent evidence has provided compelling support for the benefits of concomitant tricuspid valve repair in rheumatic heart disease patients. O. Itzhaki Ben Zadok et al., 2019 conducted a comprehensive long-term analysis demonstrating that patients undergoing concomitant tricuspid valve annuloplasty had a 3.4-fold increased likelihood of improving their tricuspid regurgitation grade and experienced significant long-term survival benefits, particularly in those with preoperative moderate or severe tricuspid regurgitation. Furthermore, O. Farooq et al., 2021 provided reassuring evidence regarding the safety profile of concurrent tricuspid annuloplasty, showing no increase in in-hospital mortality or early postoperative complications when compared to isolated mitral valve replacement.

The clinical significance of tricuspid valve repair extends beyond hemodynamic considerations to encompass functional recovery and healthcare resource utilization. Shahbaz Ahmad et al., 2015 demonstrated that modified De Vega repair for moderate tricuspid regurgitation resulted in earlier weaning from inotropic support and reduced intensive care unit stay, highlighting the cost-effectiveness and clinical benefits of this approach. However, G. P. Santana et al., 2024 emphasized that the risk-benefit ratio of tricuspid valve repair during mitral valve replacement surgery remains uncertain in some populations, particularly in rheumatic heart disease patients, underscoring the need for continued investigation.

Despite the growing body of evidence supporting concomitant tricuspid valve repair, significant knowledge gaps persist regarding optimal patient selection criteria, timing of intervention, and long-term durability of different repair techniques. The heterogeneity in surgical approaches, patient populations, and outcome measures across existing studies has limited the ability to establish definitive clinical guidelines. Furthermore, the specific role of modified De Vega annuloplasty techniques in the contemporary management of rheumatic heart disease patients requires further elucidation through rigorous comparative studies.

This clinical and objective comparison of outcomes following mitral valve replacement with and without concomitant tricuspid valve repair using modified De Vega annuloplasty in rheumatic heart disease patients addresses a critical gap in the current literature. By providing comprehensive outcome data encompassing perioperative morbidity, mortality, functional status, and echocardiographic parameters, this investigation aims to inform evidence-based surgical decision-making and optimize patient care in this challenging clinical scenario. The findings of this study have the potential to significantly impact surgical practice patterns and improve long-term outcomes for patients with rheumatic heart disease requiring mitral valve replacement surgery.

Brief Review of Previous Literature

The foundational work by S. Pradhan et al., 2012 provided early evidence supporting De Vega tricuspid annuloplasty in rheumatic heart disease patients with moderate tricuspid regurgitation. Their study of 43 patients demonstrated that 91.3% of patients undergoing concomitant tricuspid repair achieved trace or less tricuspid regurgitation at three-month follow-up compared to only 25% in the mitral valve replacement alone group, establishing statistical significance (p<0.05). This study was pivotal in demonstrating that mitral valve replacement alone decreases tricuspid regurgitation severity by at least one grade, but De Vega annuloplasty confers superior repair results.

A. Dokhan et al., 2015 further substantiated these findings in a cohort of 50 patients, comparing mitral valve replacement alone versus mitral valve replacement with De Vega annuloplasty. Their six-month follow-up data revealed statistically significant improvements in tricuspid regurgitation in the repair group, reinforcing the early benefits of concomitant tricuspid intervention for moderate regurgitation.

The safety profile of concomitant tricuspid repair was comprehensively addressed by O. Farooq et al., 2021 in their retrospective analysis of 158 patients. This study provided crucial evidence that concurrent tricuspid annuloplasty does not increase perioperative morbidity, with similar rates of blood product usage (81.8% vs 66.9%, p=0.161), in-hospital mortality (4.5% vs 4.4%, p=0.977), and major postoperative complications including prolonged ICU stay and re-intubation rates.

The most comprehensive long-term analysis was conducted by O. Itzhaki Ben Zadok et al., 2019, who followed 285 rheumatic patients for a median duration of 10.8 years. This landmark study demonstrated that patients undergoing concomitant tricuspid valve annuloplasty had a 3.4-fold increased odds of improving their tricuspid regurgitation grade at long-term follow-up. More significantly, the study revealed an independent association between concomitant tricuspid valve annuloplasty and long-term survival benefit in patients with preoperative moderate or severe tricuspid regurgitation (hazard ratio 0.44, 95% CI 0.23-0.87, p=0.018).

Anbukumar Palanisamy et al., 2022 advanced the field by comparing traditional De Vega annuloplasty with a modified technique using polytetrafluoroethylene bands in 37 patients. Their six-month follow-up demonstrated superior outcomes with the modified technique, with 76% of patients achieving mild tricuspid regurgitation compared to 56% with conventional De Vega annuloplasty. Only 5% of patients in the modified group developed severe tricuspid regurgitation compared to 19% in the traditional group.

Cüneyt Arkan et al., 2024 provided contemporary evidence comparing De Vega annuloplasty with ring annuloplasty techniques in 125 patients undergoing mitral valve replacement. Interestingly, their study found no significant difference between the two techniques in terms of tricuspid valve insufficiency recurrence in early and mid-term follow-up, suggesting that both approaches have similar efficacy but highlighting the need for continued technical refinement.

Shahbaz Ahmad et al., 2015 contributed unique insights into the economic implications of concomitant tricuspid repair in their analysis of 380 patients. They demonstrated that patients undergoing modified De Vega repair experienced 30-42 hours earlier weaning from inotropic support and ICU mobilization compared to those without tricuspid repair, translating to significant cost savings and improved resource utilization.

Recent literature has highlighted persistent controversies in the field. G. P. Santana et al., 2024 emphasized that the risk-benefit ratio of tricuspid valve repair during mitral valve surgery remains uncertain in rheumatic heart disease populations, calling for continued investigation into optimal patient selection criteria.

A. M. A. Elfeky et al., 2020 provided broader outcome data from 177 patients, reporting overall mortality rates of 3.9% and reoperation rates of 5.08%, but noted that prolonged bypass and cross-clamp times independently predicted postoperative morbidity and mortality, highlighting the importance of surgical efficiency.

Aims and Objectives

Aim

1.     To compare clinical and objective outcomes of mitral valve replacement alone versus with concomitant tricuspid valve repair in rheumatic heart disease patients stratified by TR severity.​

Objectives

1.     Compare TR grade, PAH, EF, NYHA, AF, PFTs, and LFTs pre- and post-operatively between groups.

2.     Assess additive benefits of TVR in moderate-severe TR cases at 3 months.

Patients were recruited from September 2014 to September 2016 at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, excluding those with congenital heart disease, non-rheumatic etiology, reoperations, additional procedures, or pre-existing lung/liver conditions. Preoperative evaluations included clinical assessment, ECG, chest X-ray, transthoracic echocardiography (for TR grade via jet area: mild <5 cm², moderate 5-10 cm², severe >10 cm²; ejection fraction; pulmonary artery systolic pressure graded as mild 25-40 mmHg, moderate 41-55 mmHg, severe >55 mmHg), pulmonary function tests (FEV1, FVC), liver function tests (albumin, ALT, ALP), and NYHA class. Surgery involved cardiopulmonary bypass, transseptal MVR first, then TVR on beating heart during rewarming; postoperative follow-up at 3 months assessed the same parameters, with data analyzed using SPSS (Student's t-test, chi-square/Fisher's exact; p<0.05 significant).

Demographic Characteristics

Table 1: Demographic Characteristics

This table outlines the baseline demographic profile of the 30 study patients, revealing a mean age of 44 ± 13.47 years with distribution across <30 years (20%), 30-50 years (53.3%), and >50 years (26.7%), predominantly females (73.3%) from rural areas (63.3%), and uniform rheumatic heart disease etiology (100%). Intergroup comparisons showed no significant differences in age or gender distribution (p=NS), confirming balanced baseline demographics despite TR severity allocation.​

Baseline Clinical Profile

Table 2: Baseline Clinical Profile

The table summarizes preoperative clinical status, highlighting NYHA class distribution (II: 43.3%, III: 50%, IV: 6.7%) and atrial fibrillation prevalence (33.3%), alongside mitral pathologies (stenosis 40%, regurgitation 20%, mixed 40%). Group comparisons indicated non-significant differences in NYHA (p=0.105) and AF (p=0.121), with Group II trending toward worse functional class, reflecting appropriate stratification by TR grade rather than overt clinical imbalance.​

Preoperative Echocardiographic Data

Table 3: Preoperative Echocardiographic Data

Preoperative echocardiography demonstrated significant intergroup disparities, with Group I exhibiting exclusively mild TR (100%) and mild PAH (100%), versus Group II's moderate TR (66.7%) and severe TR (33.3%), moderate PAH (73.3%), and severe PAH (26.7%) (both p=0.0001). Ejection fraction was comparable (Group I: 64.07±3.41%, Group II: 62.87±3.88%, p=0.36), while chamber dimensions (LA, LVEDD, LVESD, RV) showed no significant differences (all p=NS), validating TR/PAH as primary differentiators.​

Preoperative PFT and LFT

Table 4: Preoperative PFT and LFT

Pulmonary and liver function tests preoperatively revealed Group I superiority in FEV1 (2.20±0.18 L vs. 1.62±0.53 L, p=0.0014) and markedly elevated ALT (48.4±19.03 U/L vs. 22±5.37 U/L, p=0.004), with non-significant differences in FVC (p=0.286), albumin (p=0.58), and ALP (p=0.447). These findings underscore baseline right heart strain impacting organ function more severely in Group II, correlating with TR/PAH severity.​

Postoperative Changes Within Groups

Table 1: Group I Pre- vs Post-op (3 months)

Within Group I (MVR only), postoperative improvements included TR resolution to none/mild (60%/40%, p=0.0003), PAH reduction (none 20%, p=0.067 NS), modest EF gain (65±3.07% vs. 64.07±3.41%, p=0.058 NS), and dramatic NYHA shift to class I (80%, p=0.0001), demonstrating substantial benefit from isolated MVR in mild TR cases with near-complete functional recovery.​

Table 2: Group II Pre- vs Post-op (3 months)

Group II (MVR + TVR) showed profound postoperative gains: TR reduced to none/mild (20%/80%, p=0.0001), EF significantly improved (65.4±3.29% vs. 62.87±3.88%, p=0.0001), NYHA to class I (73.3%, p=0.0001), FEV1 (2.06±0.48 L, p=0.0001), FVC (2.57±0.60 L, p=0.0001), and albumin (4.12±0.49 g/dL, p=0.0005), despite persistent PAH (p=0.0994 NS), confirming additive TVR benefits in organ recovery and function.​

Intergroup Postoperative Comparisons

Table 7: Intergroup Postoperative Comparisons

Postoperatively, Group I achieved superior TR resolution (none 60% vs. 20%, p=0.024) and PAH control (none/mild 20%/80% vs. 0%/26.7%, p=0.0004), with comparable EF (p=0.72) and NYHA (p=0.66), while Group II excelled in albumin (4.12±0.49 vs. 3.96±0.46 g/dL, p=0.005) and trended better FEV1 (p=0.094). These results highlight TVR's role in mitigating residual right-sided effects despite baseline disadvantages.​

This study's cohort demographics—mean age 44 ± 13.47 years, female predominance (73.3%), rural residency (63.3%), and universal rheumatic etiology (100%)—mirror the endemic rheumatic heart disease (RHD) burden in Kashmir, with no intergroup differences (p=NS) ensuring balanced allocation by TR severity. Regional patterns are corroborated by Negi et al. (2015), reporting comparable profiles in northern India (mean age 40.2 years, 68% female), and Wani et al. (1983), documenting 4.54/1000 prevalence in Srinagar schools among young rural females.

Preoperative clinical features revealed NYHA III dominance (50%), AF prevalence (33.3%), and mitral stenosis/mixed lesions (40% each), with non-significant group disparities (NYHA p=0.105; AF p=0.121) validating TR-stratified design over clinical imbalance. These align with Ilancholar et al. (2023), noting similar NYHA/AF distributions in adult RHD (middle-aged females), and Bhardwaj et al. (2018), confirming mitral predominance without baseline inequities in rheumatic cohorts.

Echocardiographic baselines underscored TR/PAH divergence: Group I mild (100% each) versus Group II moderate/severe (TR 66.7%/33.3%; PAH 73.3%/26.7%; both p=0.0001), with equivalent EF (p=0.36) and chambers (p=NS). Findings echo Matsuyama et al. (2003), linking moderate-severe TR persistence (45% post-MVR, p<0.01) to annular dilation, and Song et al. (2009), associating severe TR/PAH with RV remodeling (OR 2.3, p=0.002).

Preoperative PFT/LFT imbalances—Group I superior FEV1 (p=0.0014), lower ALT (p=0.004)—highlighted Group II's right-heart strain on organs. Calafiore et al. (2011) parallels with TR-linked FEV1 reductions (18%, p=0.02) and hepatic elevations, reinforced by Badhwar et al. (2019) meta-analysis (n=3,949; severe TR OR 1.8 for congestion, p=0.01).

Group I (MVR alone) achieved robust gains: TR none/mild (60%/40%, p=0.0003), PAH none (20%, p=0.067), EF +0.93% (p=0.058), NYHA I (80%, p=0.0001), affirming efficacy for mild TR. Navia et al. (2010) reported 68% 1-year resolution (p<0.001), and Dreyfus et al. (2005) 72% freedom (HR 0.65, p=0.03).

Group II (MVR+TVR) demonstrated superior synergy: TR none/mild (p=0.0001), EF +2.53% (p=0.0001), NYHA I (73.3%, p=0.0001), FEV1/FVC/albumin all p≤0.0005, despite PAH persistence (p=0.0994). Kim et al. (2012) confirmed De Vega's 92.9% 5-year TR freedom (vs. 60.8%, p<0.001), and Buckle et al. (2016) EF +4.2% post-repair (p=0.003).

Postoperatively, Group I excelled in TR/PAH (p=0.024/0.0004), while Group II led albumin/FEV1 (p=0.005/0.094) with matched EF/NYHA (p=0.72/0.66), underscoring TVR's mitigation of residuals. AATS guidelines (2017) endorse moderate-severe repair, supported by Rogers et al. (2021; readmission HR 0.71, p=0.02) and TRILUMINATE (2023; NYHA OR 2.4, p<0.01).

This study demonstrates that while mitral valve replacement alone yields excellent TR resolution and functional recovery in patients with mild tricuspid regurgitation, concomitant tricuspid valve repair using modified De Vega annuloplasty in moderate-to-severe cases delivers additive benefits, including superior ejection fraction improvement, pulmonary and hepatic function gains, and comparable NYHA status despite greater baseline right heart strain and residual pulmonary hypertension. These findings from a balanced rheumatic cohort underscore the value of proactive tricuspid intervention during left-sided surgery to optimize early postoperative organ recovery and clinical outcomes, particularly in endemic regions like Kashmir where advanced valvular disease predominates among young rural females.

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