Optimizing Mitral Valve Repair: The Role of Concomitant Tricuspid Annuloplasty

A new systematic review and meta-analysis clarifies the role of concomitant tricuspid annuloplasty added to mitral valve repair for degenerative mitral regurgitation. The pooled analysis included five comparative cohorts totaling ~3,123 patients and focused on survival and progression of tricuspid regurgitation (TR). Overall, concomitant annuloplasty produced a durable reduction in TR progression without a survival penalty.

Practice has varied: many centers have applied selective annuloplasty based on baseline TR grade or annular dilatation, while others debated routine prophylactic repair. The new pooled data sharpen the trade-off between preventing late TR and adding operative complexity (including conduction risks), shifting the decision toward preserving long-term valve competence when baseline risk of progressive TR is appreciable.

Survival was comparable between concomitant annuloplasty and isolated mitral repair at early and late follow-up. One-year survival was similar (97.3% vs 96.9%; HR 1.25, 95% CI 0.76–2.08, p=0.381), and long-term analyses showed no significant difference (HR 1.28, 95% CI 0.96–1.72, p=0.092). Sensitivity analyses in randomized and propensity-matched cohorts confirmed nondifferential mortality, indicating survival outcomes alone do not justify routine tricuspid repair.

Concomitant tricuspid annuloplasty substantially reduced progression to ≥moderate TR (pooled HR 0.34, 95% CI 0.17–0.70, p=0.003) and improved freedom from ≥moderate TR at 5–15 years. Absolute estimates favored repair (approximately 97.5% vs 93.7% freedom at 5 years), and the protective effect persisted across long-term follow-up in sensitivity analyses. Prevention of TR progression is therefore the principal efficacy advantage of adding annuloplasty to mitral repair.

The main procedural downside was a higher rate of permanent pacemaker implantation with concomitant annuloplasty (7.4% vs 1.1%; HR 5.76, 95% CI 3.13–10.59), with increased risk persisting up to two years in pooled analyses. Operative time and bleeding signals were modest and inconsistently reported across cohorts.