Long-term results of clover and edge-to-edge leaflet repair for complex tricuspid regurgitation

BACKGROUND Aim of the study was to report the long-term results of the clover and edge-to-edge repair for complex tricuspid regurgitation(TR). METHODS This was a single-center observational study. A competing risks proportional-hazards regression model, following the Fine-Gray model, was performed to analyze the time to TR≥2+, considering death as a competing risk. RESULTS Hundred forty-five consecutive patients (female 57%) with severe or moderately-severe tricuspid regurgitation due to leaflets prolapse/flail(115 pts), tethering(27 pts) or mixed(3 pts) lesions underwent clover(110 pts) or edge-to-edge repair(35 pts).TR etiology was degenerative in 75% of cases, post-traumatic in 8% and secondary to dilated cardiomyopathy in 17%. Ring(64%) or suture(31%) annuloplasty was performed in 95% of patients. Concomitant procedures (mainly mitral surgery) were performed in 80% of cases.Hospital death was 5.5%. Follow-up was 98% complete, median 15[14-17] years. The 16-years overall survival was 56±5%. Previous cardiac surgery(HR 2.83, 95%CI 1.15-6.93, P=0.023) and right ventricle dysfunction(HR 2.24, 95%CI 1.01-4.95, P= 0.046) were identified as predictors of death.The 16-years Cumulative incidence function(CIF) of cardiac death with non-cardiac death as competing risk was 19.6% and previous cardiac surgery(HR 3.44, 95%CI 1.23-9.65, P=0.019) was detected as the only predictor of the event.At 16-years, CIF of TR≥2+ with death as competing risk was 23.8%. Particularly, TR≥3+ was detected in 4 patients(3%). CONCLUSIONS When tricuspid regurgitation could not be treated by annuloplasty alone, concomitant leaflet repair with the clover/edge-to-edge technique effectively restored valve competence with very satisfactory long-term results and low rate of moderate or greater TR recurrence.