What is the next treatment plan for a patient with severe eccentric mitral valve regurgitation, severe pulmonary hypertension, and severe tricuspid valve regurgitation?

Treatment Plan for Severe Eccentric Mitral Regurgitation with Severe Pulmonary Hypertension and Tricuspid Regurgitation

Surgical intervention addressing both mitral and tricuspid valves is strongly indicated for this patient with severe eccentric mitral regurgitation, severe pulmonary hypertension, and severe tricuspid regurgitation to reduce mortality and improve quality of life. 1

Rationale for Combined Valve Surgery

The patient presents with a complex valvular heart disease scenario characterized by:

• Severe eccentric mitral regurgitation
• Severe pulmonary hypertension (PASP 85 mmHg)
• Severe tricuspid regurgitation

This combination represents advanced valvular heart disease with secondary right heart involvement:

1. The severe mitral regurgitation is likely the primary pathology
2. Pulmonary hypertension has developed as a consequence of left-sided heart disease
3. Tricuspid regurgitation is secondary (functional) due to right ventricular dilation from pulmonary hypertension

Surgical Approach

Mitral Valve Intervention

• Mitral valve repair is strongly preferred over replacement when technically feasible 1
• Repair techniques depend on the specific pathology causing the eccentric regurgitation (leaflet prolapse, chordal rupture, etc.)
• If repair is not feasible, mitral valve replacement with chordal preservation should be performed

Tricuspid Valve Intervention

• Concomitant tricuspid valve repair is indicated due to the presence of severe tricuspid regurgitation 1
• Ring annuloplasty with a rigid or semi-rigid ring is the preferred technique for functional tricuspid regurgitation 1
• If the tricuspid valve leaflets are significantly tethered or the annulus is severely dilated, tricuspid valve replacement may be necessary 1

Preoperative Considerations

Risk Assessment

• Comprehensive evaluation of:
  • Right ventricular function
  • Pulmonary vascular resistance
  • Left ventricular function
  • Coronary anatomy

Specific Concerns

• The severe pulmonary hypertension (PASP 85 mmHg) represents a significant surgical risk factor
• Assessment of pulmonary hypertension reversibility is crucial:
  • If primarily due to mitral valve disease, it may improve after mitral valve surgery
  • If fixed pulmonary hypertension is present, surgical risk is substantially higher

Medical Management Prior to Surgery

1. Optimize volume status:

   • Diuretic therapy (loop diuretics) to reduce congestion 2
   • Consider aldosterone antagonists for hepatic congestion often seen with severe TR 2

2. Pulmonary hypertension management:

   • If vasoreactive, calcium channel blockers may be considered
   • For non-vasoreactive patients, pulmonary vasodilators may be needed preoperatively 2

Potential Pitfalls and Complications

1. Right ventricular failure:

   • The combination of severe TR and severe pulmonary hypertension indicates significant right heart compromise
   • Postoperative right ventricular failure is a major concern

2. Residual pulmonary hypertension:

   • May persist despite successful mitral valve surgery, especially if longstanding

3. Contraindications to consider:

   • Irreversible severe RV dysfunction
   • Irreversible liver cirrhosis
   • Advanced forms of leaflet tethering with very large annuli 2

Postoperative Management

1. Close hemodynamic monitoring:

   • Right heart function
   • Pulmonary pressures
   • Volume status

2. Continued medical therapy:

   • Diuretics for volume management
   • Pulmonary vasodilators if pulmonary hypertension persists

3. Regular echocardiographic follow-up:

   • Assess valve function
   • Monitor right ventricular function
   • Evaluate pulmonary pressures

Alternative Considerations

If the patient is deemed at prohibitively high surgical risk:

• Transcatheter options may be considered, though these are still emerging for combined mitral and tricuspid disease 3
• For isolated severe TR in high-risk patients, transcatheter tricuspid valve repair may be considered at specialized heart valve centers 2

Conclusion

The presence of severe mitral regurgitation with severe pulmonary hypertension and severe tricuspid regurgitation represents advanced valvular heart disease requiring prompt intervention. Combined surgical repair/replacement of both mitral and tricuspid valves offers the best chance for improved survival and quality of life, provided the patient can tolerate the surgical risk.