Tricuspid annuloplasty: prosthetic ring outperforms suture against recurrence

Functional TR recurrence: a surgical planning challenge

The recurrence of functional tricuspid regurgitation (TR) after combined mitro-tricuspid surgery remains a formidable complication, associated with an unfavorable long-term prognosis. For the cardiac surgeon, the challenge is critical: if TR persists or reappears, an isolated reintervention on the tricuspid valve exposes the patient to a substantial operative risk. Despite an increasing awareness of the prognostic impact of the tricuspid valve, the use of concomitant repair remains inconsistent in contemporary practice, particularly during technically demanding procedures.

The FuTURe study (FUnctional Tricuspid Update Study of REcurrence) was designed to address this issue by analyzing 178 consecutive patients operated on in a single center between January 2012 and June 2019. The primary objective was to identify clinical, echocardiographic, and operative predictors of TR recurrence in order to develop an individualized prediction model: the FuTURe nomogram.

The authors tested the hypothesis that precise risk stratification, including the impact of the repair technique (suture vs. prosthetic ring), would allow for the estimation of 5-year recurrence-free survival. The ambition is to shift from an assessment of immediate procedural success toward personalized management of the patient's long-term clinical trajectory.

FuTURe study methodology

This ambispective monocentric study focused on a cohort of 178 consecutive patients who underwent concomitant mitral and tricuspid valve surgery between January 2012 and June 2019. The protocol combined a retrospective collection of baseline clinical, echocardiographic, and operative data with long-term prospective clinical and echocardiographic follow-up.

The analysis focused on identifying predictive factors for the recurrence of functional tricuspid regurgitation (TR). The variables evaluated included:

• Sex, dyslipidemia and left ventricular ejection fraction (LVEF < 45 %).
• The severity of preoperative TR and the indexed tricuspid annular diameter.
• The surgical strategy employed: suture annuloplasty versus prosthetic ring annuloplasty.

In terms of statistics, the authors used Cox proportional hazards models in univariate and then multivariate analysis to isolate independent predictors of recurrence. An internal validation by bootstrap resampling was performed to ensure the robustness of the model. Finally, the regression coefficients were converted into an individualized exploratory nomogram (FuTURe nomogram) aimed at estimating 5-year recurrence-free survival of TI.

Analysis of recurrence predictors for functional TR

The FuTURe study focused on a cohort of 178 consecutive patients who underwent combined mitral and tricuspid surgery. The analysis of the data, collected over a period spanning from January 2012 to June 2019, identified the variables impacting the stability of long-term valvular repair.

Univariate analysis using the Cox model highlighted several clinical and echocardiographic risk factors associated with the recurrence of tricuspid regurgitation (TR):

• Patient profile: Female and dyslipidemia.
• Cardiac function: Left ventricular ejection fraction (LVEF) < 45 %.
• Valvular morphology: Severe preoperative TR and high indexed tricuspid annular diameter.
• Surgical technique: Suture annuloplasty (De Vega or similar).

Superiority of the prosthetic ring in multivariate analysis

The major result of this study lies in the multivariate analysis: the surgical repair strategy proved to be the sole independent predictor of TI recurrence. The data confirm a significant difference in performance between the two main approaches:

Based on these regression coefficients, the authors developed the FuTURe nomogram. This individualized prediction tool allows for estimating the probability of recurrence-free TI survival at 5 years. This model integrates the aforementioned variables to provide perioperative risk stratification, shifting the focus from simple immediate procedural success toward long-term management of the patient's clinical trajectory.

Clinical significance and practical impact

The results of the FuTURe study unequivocally demonstrate that the surgical strategy is the central pivot of long-term valvular stability. The identification of suture annuloplasty as the sole independent predictor of tricuspid regurgitation (TR) recurrence highlights a major technical flaw: suture alone does not durably counteract annular remodeling forces. For the cardiac surgeon, this confirms that prosthetic ring implantation should no longer be an option, but the systematic standard, even in complex mitral-tricuspid procedures.

The originality of this work lies in the creation of the FuTURe nomogram. By integrating clinical and echocardiographic variables (female sex, dyslipidemia, LVEF < 45%, initial TR severity, and indexed annular diameter), this tool allows for a shift from a standardised approach to a personalised stratification of the 5-year recurrence risk. This "lifetime management" perspective is crucial to avoid isolated reinterventions on the tricuspid valve, for which morbi-mortality remains high.

Limits and perspective

Although the data are robust, the monocentric nature and ambispective design of the study on 178 patients require a certain degree of caution. The FuTURe nomogram, while validated by internal bootstrap, remains an exploratory model requiring external validation on multicentric cohorts. Nevertheless, these results align perfectly with current literature while providing an individual predictive dimension that was missing from general recommendations.

Summary of results

The FuTURe study (n=178) identifies the surgical repair strategy as the sole independent predictor of tricuspid regurgitation (TR) recurrence following combined mitro-tricuspid surgery. The data demonstrate a clear superiority of the prosthetic ring over suture annuloplasty in ensuring 5-year recurrence-free survival.

In concrete terms, for the practitioner:

• Systematically prioritize the prosthetic ring: suture annuloplasty is associated with a significantly higher risk of failure. Ring implantation remains the standard to ensure long-term valvular stability.
• Target high-risk profiles: be particularly vigilant with patients presenting an LVEF <45% or severe preoperative TR, factors correlated with increased repair fragility.
• Adopt personalized planning: use stratification tools such as the FuTURe nomogram to anticipate the patient's clinical trajectory over 5 years and adapt the aggressiveness of the surgical procedure from the initial intervention.

Technical lexicon of the FuTURe study

Functional tricuspid insufficiency (TI): Regurgitation of the tricuspid valve resulting from annular dilatation or remodeling of the right cavities, as opposed to primary organic involvement of the valve leaflets.

Annuloplasty on a prosthetic ring: Surgical repair technique consisting of implanting an artificial ring to stabilize and reduce the diameter of the tricuspid annulus; identified in the study as the only independent predictor of lower recurrence.

Suture annuloplasty: A method of valvular repair without prosthetic support, using sutures to reduce the circumference of the annulus, associated by multivariate analysis with a significantly higher risk of TR recurrence.

Ambispective study: Research design combining retrospective data collection (baseline clinical and echocardiographic variables between 2012 and 2019) and prospective patient follow-up after ethical approval.

FuTURe Nomogram: Individualized perioperative prediction tool developed from Cox model regression coefficients, allowing the estimation of 5-year recurrence-free survival of tricuspid regurgitation for a given patient.

Cox model (proportional hazards): Multivariate statistical analysis used to identify variables (clinical, echocardiographic, or operative) independently associated with the time to recurrence of TR.

Bootstrap resampling: Internal validation method for the predictive model consisting of generating multiple sub-samples from the original data to test the robustness of the nomogram.

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