Long-term results (up to 14 years) of the clover technique for the treatment of complex tricuspid valve regurgitation

OBJECTIVES: To report the long-term results of the clover technique for the treatment of complex forms of tricuspid regurgitation (TR). METHODS: Ninety-six consecutive patients (mean age 60 +/- 16.4, left ventricular ejection fraction 58 +/- 8.8%) with severe or moderately-severe TR due to important leaflets prolapse/flail (81 patients), tethering (13 patients) or mixed (2 patients) lesions underwent clover repair combined with annuloplasty. The aetiology of TR was degenerative in 74 cases (77.1%), post-traumatic in 9 (9.4%) and secondary to dilated cardiomyopathy in 13 (13.5%). All patients but 3 (96.8%) underwent ring (59 patients, 61.5%) or suture (34 patients, 35.4%) annuloplasty. Concomitant procedures (mainly mitral surgery) were performed in 82 patients (85.4%). RESULTS: Hospital mortality was 7.2%. At hospital discharge 92 (95.8%) patients had no or mild TR. Follow-up was 98% complete (median 9 years, interquartile range 5.1; 10.9). At 12 years the overall survival was 71.6 +/- 7.22% and the cumulative incidence function of cardiac death with non-cardiac death as competing risk 16 +/- 4.1% [95% confidence interval (95% CI) 9.5-25.7]. At 12 years the cumulative incidence function of TR 3+ and TR 2+ with death as competing risk were 1.2 +/- 1.2% (95% CI 0.1-5.8) and 28 +/- 7.7% (95% CI 14.3-43.5), respectively. Preoperative left ventricular ejection fraction (hazard ratio 0.9, CI 0.9-1, P = 0.05) and previous cardiac surgery (hazard ratio 2.7, 95% CI 1-7.1, P = 0.03) were predictors of recurrent TR 2+ at univariable but not at multivariable analysis. CONCLUSIONS: Complex forms of TR due to severe prolapse or tethering of the leaflets can be effectively treated with the clover technique with very satisfactory long-term results and extremely low recurrence of severe TR.