Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

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Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by
a low degree of right chambers’ remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA)
dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography
(3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression.
We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular
function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR) ≤ mild; no concomitant cardiac disease.
All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were
divided in Group 1 (N = 68, 43%, TAD, TA ≥ 21 mm/m2) and Group 2 (N = 91, 57%, no TAD, TA < 21 mm/m2). By 3DE,
Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group
2 (p < 0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated
to TA size (p < 0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression
in Group 1 (p = 0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset
geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated
approach, including right chambers’ assessment by 3DE, might help to better recognized patients at higher risk for TAD
and, potentially for FTR.