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Functional Tricuspid Regurgitation in Organic Mitral Regurgitation. New Insights into Right ventricular function.
Thierry Le Tourneau1, Caroline Cueff1, Marjorie Richardson2, Claude Hossein-Foucher2, Georges Fayad2, Jean-Christian Roussel1, Jean-Noel Trochu1, André Vincentelli2.
1Institut du Thorax, Nantes, France, 2University Hospital, Lille, France.

OBJECTIVE: To assess the determinants of functional tricuspid regurgitation (TR) and its relations to right ventricular (RV) function in chronic organic mitral regurgitation (MR).
METHODS: Three-hundred twenty-five patients (63±12 years, 206 males) with organic MR (82% degenerative etiology) referred to surgery and who underwent a preoperative gradation of TR were included in this study. Radionuclide angiography was carried out in 237 patients.
RESULTS: Fifty patients had a TR ≥ grade 2. Patients with TR ≥ 2 were older, had more AF (54 vs 24%, P<0.0001) and were more symptomatic. Mean LV EF and RV EF were lower, and LV septal function and RV free wall function were impaired in those with TR ≥ 2. By echocardiography, LV-RV, left and right atrial remodeling were worse, PASP was higher and inter ventricular systolic pressure was lower whereas the severity of MR was similar. RV S velocity was also significantly decreased. Ventricular function was stratified in normal RV-LV (Normal), isolated RV dysfunction (RVdysf, RV EF≤35%), isolated LV dysfunction (LVdysf, LV EF<60%), and biventricular impairment (BiV, LV EF<60% and RV EF≤35%). TR ≥ 2 was found mainly in either BiV (33%) or LVdysf (22%) but almost never in RVdysf (3%) nor Normal (3%) groups. In BiV TR ≥ 2 was associated with overall impairment of the right heart while only the RA-annulus-RV base were enlarged in LVdysf. Finally RV EF alteration in RVdysf was likely linked mainly to compression and flattening of the RV by the severely enlarged LV owing to severe volume overload. Moreover, in RVdysf RV S wave velocity was not reduced and RV EF improvement after surgery was greater suggesting limited impairment of intrinsic myocardial function. These specific features probably explain the absence of TR in this subgroup of patients.
CONCLUSIONS: In patients with organic MR referred to surgery TR ≥ 2 is associated with the longstanding consequences of chronic organic MR. Tricuspid regurgitation occurs mainly in patients with BiV or LVdysf but is almost absent in RVdysf or Normal groups. Finally RVdysf group exhibits features suggesting a direct reversible effect of the magnitude of volume overload on the RV.

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