Percutaneous Mitral Valvuloplasty Versus Surgical Treatment in Mitral Stenosis With

Severe Tricuspid Regurgitation

Hyun Song, Duk-Hyun Kang, Jeong Hoon Kim, Kyoung-Min Park, Jong-Min Song, Kee-Joon
Choi, Myeong-Ki Hong, Cheol Hyun Chung, Jae-Kwan Song, Jae-Won Lee, Seong-Wook Park
and Seung-Jung Park

Circulation. 2007;116:I-246-I-250
doi: 10.1161/CIRCULATIONAHA.107.678151
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2007 American Heart Association, Inc. All rights reserved.
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 Percutaneous Mitral Valvuloplasty Versus Surgical
Treatment in Mitral Stenosis With Severe
Tricuspid Regurgitation
Hyun Song, MD, PhD; Duk-Hyun Kang, MD, PhD; Jeong Hoon Kim, MD; Kyoung-Min Park, MD;
Jong-Min Song, MD, PhD; Kee-Joon Choi, MD, PhD; Myeong-Ki Hong, MD, PhD;
Cheol Hyun Chung, MD, PhD; Jae-Kwan Song, MD, PhD; Jae-Won Lee, MD, PhD;
Seong-Wook Park, MD, PhD; Seung-Jung Park, MD, PhD

Background—The persistence of significant tricuspid regurgitation (TR) after percutaneous mitral valvuloplasty (PMV) is
known to be an independent predictor of adverse outcome in mitral stenosis (MS). However, it remains unclear whether
mitral valve (MV) surgery combined with surgical correction of TR is the better treatment option than PMV in patients
with severe MS and severe functional TR.
Methods and Results—We included a total of 92 consecutive patients (18 men, age 49⫾13 years) with severe MS and
severe functional TR, who were potential candidates for PMV from 1997 to 2005, and the exclusion criteria were
defined as the presence of left atrial thrombi, mitral regurgitation ⱖgrade 3, echo score ⬎10, and left ventricular ejection
fraction (EF) ⬍35%. PMV was performed on 48 patients (PMV group), and MV surgery combined with tricuspid valve
(TV) repair was performed on 44 patients (TVP group). The clinical events were defined as death, repeat surgical or
percutaneous intervention, and readmission because of heart failure. There were no significant differences between the
2 groups in terms of gender, baseline EF, and baseline severity of pulmonary hypertension, but patients in the TVP group
were older and had a higher echo score and a higher incidence of atrial fibrillation than those in the PMV group. During
follow-up of 57⫾35 months, 2 deaths occurred in the TVP group, and there were 2 deaths, 7 cases of heart failure
requiring surgical intervention in the PMV group. The difference of event rates between the 2 groups showed borderline
significance (P⫽0.05), but no difference in mortality was observed. The estimated actuarial 7-year event-free survival
rate was 77⫾8% in the PMV group and 95⫾3% in the TVP group. Severe TR was improved to mild or absent TR in
43 (98%) patients in the TVP group, and this was significantly higher than in the PMV group (22/48, 46%; P⬍0.001).
In the TVP group, the right ventricle (RV) size was significantly decreased in 18 (90%) patients among 20 patients with
preoperative significant RV enlargement. On stepwise multivariate logistic regression analysis, TVP group and baseline
sinus rhythm were independent predictors for improvement of TR (P⬍0.001).
Conclusions—TV repair combined with MV surgery was related to better clinical outcomes than PMV alone, and we
recommend that this surgical option should be considered preferentially in severe MS with severe functional TR,
especially if atrial fibrillation or enlarged RV is associated. (Circulation. 2007;116[suppl I]:I-246–I-250.)
Key Words: surgery 䡲 valvuloplasty 䡲 mitral stenosis 䡲 tricuspid regurgitation

F unctional tricuspid regurgitation (TR) is frequently asso-

ciated with severe mitral stenosis (MS),1– 4 because sig-
nificant MS can cause pulmonary venous and arterial hyper-
tension resulting in right ventricle (RV) dysfunction and
tricuspid annular dilatation. The clinical importance of asso-
ciated TR has been well appreciated, as persistent TR
contributes to increased morbidity and mortality despite
adequate surgical and percutaneous intervention of the mitral
valve (MV) disease. 5– 8
Although percutaneous mitral valvuloplasty (PMV) has
become the treatment of choice in selected patients with
severe MS,9 –11 its inability to correct the associated tricuspid
valve disease can be an inherent limitation, and persistent
significant TR after PMV is known as an independent
predictor of an adverse outcome.5,6 However, it is unclear
whether MV surgery with simultaneous surgical correction of
TR would be the better treatment option in patients who are
potential candidates for PMV, because MV surgery has the
morbidity and mortality related with operation, and regres-
sion of TR may result from improvement of pulmonary
hypertension by PMV.12,13 We therefore examined the hy-
pothesis that MV surgery with tricuspid valve (TV) repair is

From the Division of Cardiology, Cardiac Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
Presented at the American Heart Association Scientific Sessions, Chicago, Ill, November 12–15, 2006.
Correspondence to Duk-Hyun Kang, MD, PhD, Professor of Medicine, Division of Cardiology, Asan Medical Center, College of Medicine, University
of Ulsan, 388-1, Poongnap-dong, Songpa-ku, Seoul, Korea 138-736. E-mail dhkang@amc.seoul.kr
© 2007 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.107.678151

I-246
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 Song et al PMV vs Surgical Treatment I-247

related with more favorable clinical outcomes by reducing RV systolic pressure was considered to be equal to the pulmonary
functional TR more effectively than PMV alone. We also artery systolic pressure unless there was significant pulmonary
analyzed the effects of clinical, echocardiographic, and pro- stenosis.
cedural variables on clinical outcome and improvement of TR
in patients with severe MS and severe functional TR.
Clinical Follow-Up
The clinical follow-up ranged from 6 to 114 months. Data were
obtained during visits to the outpatient clinic or by telephone
Methods interview. The clinical events were defined as death, repeat surgical
Study Population or percutaneous intervention, and readmission because of symptom-
atic heart failure.
We included a total of 92 consecutive patients (18 men, age
49⫾13years) with severe MS (MV area ⬍1.2 cm2) and severe
functional TR, who were potential candidates for PMV from 1997 to Statistical Analysis
2005. The criteria for exclusion in the study were defined as a total Numerical data expressed as mean⫾SD values. Continuous variables
echocardiographic score ⬎10, mitral regurgitation ⱖgrade 3, left were compared using the Student paired and unpaired t tests. The ␹2
atrial thrombi, significant aortic valvular disease, and left ventricular test and Fisher exact test compared frequency ratios between groups.
(LV) ejection fraction ⬍35%. The decision to recommend PMV Wilcoxon signed-rank test was used to assess the follow-up change
alone or combined MV surgery and TV repair was at the discretion in RV size and progression of TR. Multiple stepwise logistic
of the attending physician. regression analysis was used to identify independent predictors for
improvement of TR. Kaplan-Meier analysis was used to determine
Percutaneous Mitral Valvuloplasty the event-free survival rate, and differences in survival rates between
The PMV was performed using either the double balloon or the groups were analyzed by the log-rank test. A probability value ⬍0.05
Inoue balloon technique, as described previously.14 The procedure was considered to be significant.
was performed by two experienced interventional cardiologists The authors had full access to the data and take responsibility for
during which conventional hemodynamic parameters were moni- its integrity. All authors have read and agree to the manuscript as
tored. A successful immediate result was defined as a MV area ⱖ1.5 written.
cm2 or an increase of ⱖ50% after PMV with mitral regurgitation less
than grade 3.
Results
Surgical Procedure Baseline Characteristics
All patients underwent normothermic cardiopulmonary bypass with The PMV was performed on 48 patients (PMV group),
intermittent cold blood cardioplegia. In all patients undergoing
mechanical mitral valve replacement (MVR), the posterior leaflet whereas 44 patients received MVR combined with TV repair
was preserved. After MVR, TV repair was performed using the De (TVP group). The baseline clinical and echocardiographic
Vega tricuspid annuloplasty15 or Carpentier-Edward and Duran ring characteristics of the study population were summarized in
annuloplasty. After tricuspid annuloplasty, cold saline solution was the Table. There were no significant differences between the
rapidly flushed into the right ventricle to test the competence of the
tricuspid valve. The maze operation was performed on selected
2 groups in terms of gender, predicted surgical mortality
patients with atrial fibrillation as described previously.16 calculated by logistic Euroscore, LV ejection fraction, sever-
ity of pulmonary hypertension, tricuspid annular diameter,
Echocardiographic Evaluation incidence of significant RV enlargement, or MV area, but
Echocardiographic evaluation was performed before and after either patients in the TVP group were significantly older and had a
PMV or surgery, and then annually during the follow-up. Two-
dimensional echocardiography and Doppler color flow imaging were
performed on all patients with a Hewlett-Packard Sonos 2500 or Comparison of Baseline Clinical and
5500 imaging system equipped with a 2.5-MHz transducer (Hewlett- Echocardiographic Characteristics
Packard, Andover, Mass). Transesophageal echocardiography was
performed on all patients to detect left atrial thrombi. The morpho- TVP PMV
logical features of the MV were categorized as described previous- Group Group P
ly,17 and the total echocardiographic score was obtained by adding (n⫽44) (n⫽48) Value
the score for each of the following individual morphological fea- Age, y 54⫾12 44⫾11 0.001
tures: leaflet mobility, thickness, calcification, and subvalvular
lesions. The MV area was measured by direct planimetry of the Gender, male 11 (25%) 7 (15%) NS
mitral orifice. Mitral regurgitation was detected and semiquantita- Atrial fibrillation 38 (86%) 26 (54%) 0.001
tively graded with color flow imaging. Logistic Euroscore 1.9⫾0.8 1.7⫾0.8 NS
RV size and TR were evaluated in the apical four-chamber view.
TR was graded as trace, mild, moderate, and severe when the jet area Left atrial dimension, mm 61⫾10 54⫾6 ⬍0.001
occupied 10%, 10% to 20%, 20% to 33%, ⬎33% of the right atrial LV ejection fraction, % 55⫾7 57⫾8 NS
area, respectively, in correlations with surgical and angiographic Mitral valve area, cm2 1.0⫾0.3 0.9⫾0.2 NS
data.12,18 The right atrial area was traced from the same frame as the
maximal jet area. TR was defined as having improved when the Mean mitral PG, mm Hg 13⫾7 13⫾6 NS
regurgitation was trace or mild on the 1-year follow-up echocardi- Echo score 9.1⫾1.0 7.9⫾1.2 ⬍0.001
ography. The RV was considered significantly enlarged when the
Peak TR velocity, m/sec 3.1⫾0.7 3.3⫾0.7 NS
dimension of RV which equaled to or was greater than the dimension
of LV. The tricuspid annular diameter was measured at the time of Systolic PAP, mm Hg 48⫾19 54⫾20 NS
maximal tricuspid opening as the distance from the insertion of Tricuspid annulus diameter, mm 39⫾7 36⫾6 NS
septal tricuspid leaflet to the insertion of anterior tricuspid leaflet.6
RV enlargement, % 20 (45%) 13 (27%) NS
RV systolic pressures were estimated by continuous wave Doppler
using the simplified Bernoulli equation (4⫻[peak TR velocity]2), LV indicates left ventricle; PG, pressure gradient; TR, tricuspid regurgitation;
with 10 mm Hg added for the estimated right atrial pressure.19 The PAP, pulmonary artery pressure; RV, right ventricle.

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I-248 Circulation September 11, 2007
Figure 1. Comparison of event-free survival rates of all patients
(A) and patients with atrial fibrillation (B) in the TVP and PMV
groups.
higher echo score, larger left atrium, and higher incidence of
atrial fibrillation than the PMV group (P⬍0.01).
Immediate and Long-Term Clinical Outcomes
In the PMV group, the valve area was increased from a
baseline of 0.9⫾0.2 cm2 to 1.8⫾0.3 cm2 immediately after
PMV (P⬍0.001), and an immediate successful result of PMV
was achieved in 95% (57/60) of the patients. In the TVP
group, there was no operative mortality.
Clinical follow-up was completed with 91 (99%) patients,
with a mean follow-up period of 57⫾35 months. There were
2 patient deaths in the TVP group: 1 patient died of severe LV
dysfunction at 2 months, and the other patient died of
gastrointestinal bleeding at 1 year after MVR. In the PMV
group, there were 2 deaths from heart failure at 2 and 3 years
after PMV. The estimated actuarial 7-year survival rate was
95⫾3% in the TVP group and 95⫾4% in the PMV group
(p ⫽ NS). There were no other clinical events in the TVP
group during follow-up, and in the PMV group, there were 2
cases of heart failure and 5 cases who underwent MVR
combined with TV repair (3 cases of severe TR, 1 case of
mitral restenosis with severe TR, and 1 case of severe MR
and severe TR). The event rate was 19% in the PMV group
and 5% in the TVP group, and the difference of event rates
between the 2 groups showed borderline significance
(P⫽0.05). The estimated actuarial 7-year event-free survival
rate was 77⫾8% in the PMV group and 95⫾3% in the TVP
group, and the difference did not reach the statistical signif-
icance (Figure 1A).
Because the incidences of baseline atrial fibrillation dif-
fered between the 2 groups, subgroup analysis was performed
according to cardiac rhythm. In patients with atrial fibrilla-
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tion, the event rate was significantly higher in the PMV group
(7/26) than in the TVP group (2/38, P⬍0.05) and the
estimated actuarial 7-year event-free survival rate was also
significantly lower in the PMV group (70⫾11%) than in the
TVP group (94⫾4%) (Figure 1B). In patients with sinus
rhythm, the event rates were similar in the PMV and TVP
groups (2/22 and 0/6, respectively), and the estimated actu-
arial 7-year event-free survival rates did not differ signifi-
cantly between the 2 groups.
Impact of TV Repair on Improvement of TR and
RV Remodeling
Severe TR was improved to mild or absent TR on 1-year
follow-up echocardiography in 43 (98%) patients in the TVP
group, and this was significantly higher than in the PMV
group (22/48, 46% P⬍0.001; Figure 2). The tricuspid annular
diameter was decreased significantly from 38.5⫾6.6 to
28.5⫾6.2 mm in TVP group (P⬍0.001), but was unchanged
in the PMV group (36.4⫾5.9 to 36.7⫾6.1 mm, P⫽NS). In
the PMV group, RV size was increased significantly in 5
patients and decreased significantly in 5 patients, respectively
(P⫽NS), but RV size was significantly decreased in 18 (90%)
patients among 20 patients with preoperative significant RV
enlargement in TVP group (P⬍0.001). A stepwise multivar-
iate logistic regression analysis revealed that TVP group and
baseline sinus rhythm were significant predictors for im-
provement of TR (P⬍0.001). TR improvement rates of
among patients with atrial fibrillation were 97% in the TVP
group and 23% in the PMV group (P⬍0.001), whereas
improvement rates in patients with sinus rhythm did not differ
significantly between the TVP and PMV groups (100%
versus 73%, P⫽NS). During annual echocardiographic
follow-up, mild TR had progressed to moderate TR in 7
patients and to severe TR in 1 patient, and moderate TR had
progressed to severe TR in 2 patients in the PMV group
(P⬍0.05), and in the TVP group, mild TR was progressed to
moderate TR in 2 patients with persistent atrial fibrillation
(P⫽NS). The maze operation was performed in combination
with MVR and TV repair on 21 patients, and atrial fibrillation
was converted to sinus rhythm in 16 (76%) patients. The RV
size and progression of TR did not differ significantly
between patients who did and did not have the maze
operation.
Discussion
This study demonstrates that MVR combined with TV repair
is related to better clinical outcomes than PMV alone by
improving TR more effectively in patients with severe MS
and severe functional TR.
TR in patients with MV disease may be attributable to
rheumatic involvement of the valve or to functional TR; in
the majority of cases it is functional, being a consequence of
RV dysfunction and tricuspid annulus enlargement secondary
to pulmonary hypertension.1,6 The importance of significant
TR was often neglected, but clinical recognition of TR has
assumed increasing importance because it affects the out-
come of MV surgery in several ways: (1) functional TR may
persist or recur despite correction of MV disease, (2) signif-
icant persistent TR can also contribute to progression of RV

A Pre Op
B Pre PMV
Figure 2. Severe functional TR and RV enlargement were significantly decreased by TV repair on postoperative 1-year and 5-year
follow-up echocardiography (A). Severe TR and RV size were unchanged after PMV alone (B).
cardiomyopathy that results in further aggravation of TR, and
(3) significant TR can increase morbidity and mortality
independent of pulmonary hypertension and LV ejection
fraction.20 Based on these findings, it has become common
practice to detect and correct significant functional TR at the
time of initial MV surgery. However, MVR with surgical
correction of TR has not been previously compared with
PMV in patients who are potential candidates for PMV. In
this study, TV repair was effective at decreasing the tricuspid
annular diameter and TR, and these significant changes could
lead to a reduction in RV size, prevention of TR progression,
and finally more favorable clinical outcomes compared with
PMV alone. From the results of this study, we suggest that
this surgical option should be considered preferentially,
especially if significant TR is associated with enlarged RV.
Percutaneous mitral valvuloplasty (PMV) has been ac-
cepted as an effective method of treating hemodynamically
significant MS,9 –11 but Sagie et al reported that significant TR
was closely associated with suboptimal immediate results and
poor late outcome after PMV.5 They also reported that
significant TR did not substantially decrease or resolve after
PMV in the majority of patients.6 We agree with their opinion
that the structural changes in RV may become irreversible,
causing significant functional TR to persist even after relief
of the increased pulmonary artery pressure. However, we
could observe regression of TR after PMV alone in a
subgroup of younger patients with sinus rhythm. In previous
studies, the regression of TR after PMV varied considerably
with the baseline characteristics of the study patients,6,12,13
and a clinically useful marker is needed to differentiate
chronic advanced disease from an acute decompensated state.
In this study, cardiac rhythm was significantly and indepen-
dently related with improvement of TR, and in atrial fibril-
lation, clinical outcomes were also significantly worse in the
PMV group than in the TVP group. It is also well known that
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Song et al PMV vs Surgical Treatment I-249
TVP 1 yr TVP 5 yr
PMV 1 yr PMV 6 yr
atrial fibrillation is closely related to atrial dilatation, with
long-standing pressure elevation and chronic atrial fibrillation
also leading to atrial and tricuspid annular dilatation further.21
Therefore, we suggest that the presence of atrial fibrillation is
a useful clinical marker for identifying those patients with
chronic advanced structural changes. Additionally, the throm-
boembolic risk related to atrial fibrillation also affects the
clinical benefits of PMV, because atrial fibrillation exposes
the patient to a life-long risk of thromboembolism and
anticoagulation-related bleeding after successful PMV in the
same way as MVR. The surgical option has another advan-
tage in patients with atrial fibrillation, because the maze
operation can be performed in combination with MV surgery.
It has been reported that the maze operation prevented
complications related to atrial fibrillation, such as heart
failure and thromboembolism, by converting atrial fibrillation
to sinus rhythm.22,23 Moreover, Kim et al recently reported
that the incidence of significant TR was significantly higher
in patients with postoperative atrial fibrillation, and that the
maze operation could prevent progression of TR.24
Study Limitations
This study was subject to the limitations inherent to a
nonrandomized study, including selection bias. Although the
baseline characteristics were more unfavorable in the TVP
group than in the PMV group (in terms of being older and
having a higher echo score and higher incidence of atrial
fibrillation), this study could show that TV repair was more
effective in improving TR, and it was associated with better
clinical outcomes than PMV. This study had a relatively
small number of patients, and no difference in mortality was
observed. Further prospective randomized studies are needed
to confirm our results.
I-250 Circulation September 11, 2007
Conclusions
TV repair combined with MV surgery was related to better
clinical outcomes than PMV alone by improving TR more
effectively in severe MS with severe functional TR, and we
recommend that this surgical option should be considered
preferentially, especially if atrial fibrillation or enlarged RV
is associated.
Disclosures
None
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