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J Thorac Cardiovasc Surg 2004;128:296-302
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Medical and surgical outcome of tricuspid regurgitation caused by flail leaflets

^a Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn, USA
^b Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minn, USA
^c Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn, USA

Received for publication September 24, 2003; revisions received December 19, 2003; accepted for publication January 13, 2004.

^* Address for reprints: Maurice Enriquez-Sarano, MD, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
sarano.maurice{at}mayo.edu

OBJECTIVE: We sought to evaluate the medical and surgical outcome of tricuspid regurgitation caused by flail leaflets.

METHODS: We analyzed the cause, clinical presentation, outcome, and natural history of 60 patients with tricuspid regurgitation caused by flail leaflets, a cause of mostly severe and organic tricuspid regurgitation, diagnosed by means of echocardiography between 1980 and 2000.

RESULTS: The main cause was traumatic (62%). Clinical presentation was often severe: 57% were symptomatic, 33% had a history of congestive heart failure, and 40% had a history of atrial fibrillation. Compared with expected survival of the US matched population, excess mortality (39% ± 10% at 10 years or 4.5% yearly, P < .01) was observed. Even patients asymptomatic at presentation experienced high tricuspid-related event rates (at 10 years, 75% ± 15% had symptoms or heart failure, atrial fibrillation, surgical intervention, or death). In those patients severe enlargement of right-sided chambers was predictive of poor outcome (at 5 years: 86% ± 9% vs 39% ± 11%, P < .01) independent of cause (P = .31). The poor medical outcome was further confirmed by high event rates (69% ± 9% at 15 years) in the natural history beginning from the flail's occurrence. Tricuspid operations were performed in 33 patients (55% ± 7% at 5 years), with valve repair in 82%, low mortality (3%), and, despite frequently refractory atrial fibrillation, symptomatic improvement in 88%.

CONCLUSION: Tricuspid regurgitation caused by flail leaflets is a serious disease associated with excess mortality and high morbidity. Tricuspid valve repair can often be performed with low risk, allowing symptomatic improvement. These results suggest that surgical intervention should be considered early in the course of the disease before the occurrence of irreversible consequences.

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