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\begin{document}

\title{Late tricuspid regurgitation and right ventricular remodeling after
tricuspid annuloplasty.}



\author[1]{Antonio Calafiore}%
\author[2]{Roberto Lorusso}%
\author[3]{Hatim  Kheirallah }%
\author[3]{Mojtaba   Alsaied}%
\author[3]{Juan  Alfonso}%
\author[4]{Angela Di Baldassarre}%
\author[4]{Sabina Gallina}%
\author[5]{Mario Gaudino}%
\author[6]{Michele Di Mauro}%
\affil[1]{John Paul II Foundation for Research and Treatment}%
\affil[2]{Maastricht University}%
\affil[3]{Prince Sultan Cardiac Center}%
\affil[4]{Università degli Studi Gabriele d'Annunzio Chieti Pescara Scuola di Medicina e Scienze della Salute}%
\affil[5]{NewYork-Presbyterian Hospital/Weill Cornell Medical Center}%
\affil[6]{Maastricht UMC+}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Background. We sought to determine the relationship between tricuspid
right ventricular (RV) and tricuspid valve (TV) remodeling and late
failure of tricuspid annuloplasty. Methods. From May 2009 to December
2015, 423 patients undergoing tricuspid annuloplasty (TA) for functional
TR at a single were analyzed. Residual TR was defined TR
moderate-or-more at discharge. Recurrent TR was defined
TR-moderate-or-more at follow up. RV remodeling was defined RV
dysfunction and/or dilatation. Results. Residual TR after TA was
recorded in 54. Five-year freedom from TR recurrence was 86.3\selectlanguage{ngerman}±2.3\% for
patients without residual TR vs 57.6±7.6\% for patients with residual
TR, p\textless{}0.001. Evaluating late results of 369 patients without
residual TR, following risk factors were identified: preoperative
pulmonary pressure, pre RV remodeling, pre TR and TV remodeling,
functional mitral regurgitation. Conclusions. Prophylactic tricuspid
annuloplasty should be encouraged among surgeons. TA at the time of
left-sided valve surgery should take into consideration not only annular
size, but also tethering severity and RV remodeling.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{INTRODUCTION}

Functional tricuspid regurgitation (TR) can result from enlarged annular
area and increased chordal tethering. Annular dilatation is a constant
feature and is strongly related to right atrial or ventricle (RV)
enlargement\textsuperscript{1}. \textbackslash{}soutTricuspid
regurgitation (TR) was reported in 33\% of men and in 37\% of women,
respectively\textsuperscript{2}. \textbackslash{}soutSevere TR was
associated with a very poor prognosis, independently of age, RV
dimensions, biventricular function and inferior vena cava
size\textsuperscript{3}.

The observation that TR could progress after successful MV replacement
or repair\textsuperscript{2} leaded surgeons to correct even
moderate-or-less TR with dilated annulus (\textgreater{}40 mm or
\textgreater{}21 mm/m\selectlanguage{ngerman}²). The results of surgical TR correction are,
however, still flawed, and prophylactic tricuspid annuloplasty remains
underused\textsuperscript{3}, being performed in only 10\% of patients
with MV disease\textsuperscript{4}.

This retrospective study was aimed to evaluate the relationship between
preoperative RV remodeling and both late TR recurrence and RV
remodeling, so to identify subgroups of patients at higher risk of
tricuspid annuloplasty (TA) failure, to adopt different surgical
indications and treatment strategies.

\textbf{MATERIAL AND METHODS}

From May 2009 to December 2015, 688 patients undergoing TA for
functional TR at Prince Sultan Cardiac Center, Riyadh, Saudi Arabia,
were initially scheduled for this study according to the following
criteria: (i) MV disease requiring surgical intervention; (ii) no
pathologic changes in TV leaflets; (iii) no previous TV repair; (iv) not
associated tricuspid valvuloplasty. Early results of this study have
been already reported\textsuperscript{6}. Twenty-six patients died in
the early postoperative period, so they were excluded from the analysis.
Moreover, 239 patients were lost at follow up because they came from
very far cities or neighboring states of the Arabic peninsula.

Finally 423 patients, where transthoracic echocardiographic evaluation
was performed preoperatively and at follow up, were included into the
study. Retrospective analysis of our database was approved by the
institutional review board, which waived patient consent. In 54 out of
423 (13\%) a moderate-or-more TR was recorded at the
discharge\textsuperscript{5}. Hence, we analyzed the long-term results
of two cohorts of patients: 54 with residual TR and 369 without residual
TR, with particular attention to the latter one.

Preoperative characteristics of the study patients are summarized in
Table 1.

\textbf{Echocardiographic evaluation}

In all patients, ejection fraction, left ventricular diameters were
measured by echocardiography, according to the recommendations of the
American Association of Echocardiography\textsuperscript{6}. Tricuspid
annulus, TV coaptation depth (CD) and tenting area were collected in
apical 4-chamber view. TR severity was graded as mild, moderate,
severe\textsuperscript{6}. Recurrence of TR was defined as the presence
of TR graded moderate-or-more. \emph{TV remodeling} was defined
according to at least one cutoff (CD\selectlanguage{english}[?]6.5 mm, tenting area \selectlanguage{english}[?]0.85
cm\textsuperscript{2} and tricuspid annulus\selectlanguage{english}[?]35
mm)\textsuperscript{5}.\emph{RV} \emph{dilatation} was defined as a
basal end-diastolic diameter \textgreater{}42 mm and/or mid-level
diameter \textgreater{}35 mm\textsuperscript{7,8}. \emph{RV}
\emph{dysfunction} was defined as TAPSE \textless{}16 mm and/or TDI-S'
velocity \textless{}10 cm/sec\textsuperscript{7,8}. \emph{Right
ventricular remodeling} was defined as RV dilatation and/or dysfunction.
A systolic pulmonary pressure (sPAP)\textgreater{}55mmHg was considered
as severe pulmonary hypertension\textsuperscript{7,8}. \emph{Failure of
MV surgery at follow-up} was defined MV area \selectlanguage{english}[?]1.5 cm2 and/or
moderate-or-more regurgitation.

\textbf{Surgical indications and techniques}

Moderate-or-severe TR was always corrected during MV surgery. Mild TR
was treated if systolic dimension of the annulus was \textgreater{}24
mm\textsuperscript{9}. All patients underwent surgery through a median
sternotomy. TV repair was accomplished using De Vega annuloplasty,
flexible bands (Sovering MiniBand, SMB50, Sorin, Saluggia, Italy;
Cosgrove-Edwards, Edwards Lifesciences, Irvine, CA, USA; Duran,
Medtronic, Inc, Minneapolis, MN, USA), or a rigid incomplete ring (MC3,
Edwards Lifesciences, Irvine, CA, USA). Myocardial protection was
achieved using intermittent warm antegrade and retrograde blood
cardioplegia.

\textbf{Follow-up}

The most recent clinical information was obtained by calling the patient
or the referring cardiologists. The median clinical follow-up was 41
(20-64) months. The average number of echocardiographic studies at
follow up for patients was 1.5, but we reported the last one in all
cases but when TR moderate-or-more was recorded. In those cases, the
first echocardiogram reporting recurrence was collected. The median
echocardiographic time was 35(18-58). Follow-up ended in December 2016.

\textbf{Endpoints}

The primary endpoint was \emph{TR recurrence} . The secondary end-point
was late RV remodeling later after surgery. Survival was also assessed.

\textbf{Statistical analysis}

Categorical variables are expressed as counts (percentages). Continuous
variables are presented as mean+-SD if normally distributed, and as
quartiles if non-normally distributed. Comparisons between groups were
made using unpaired 2-tailed \emph{t} -test or Mann-Whitney U test;
Pearson's chi-square test for categorical variables. Pre- and
postoperative data of each group were compared by paired \emph{t} -test
or Wilcoxon-test. ROC curve analysis was used to determine different
cut-offs. Cox proportional hazards regression models were used for
either TR recurrence or late RV remodeling, and reported as the hazard
ratio with 95\% confidence intervals. In case of correlation between
covariates, different models were built. For all tests, a p-value of
\textless{}0.05 was considered statistically significant. The SPSS
software (SPSS Inc., Chicago, IL, USA) and R~Core Team (2013).~(R:
Vienna, Austria. URL\emph{http://www.R-project.org/}) were used.

\textbf{RESULTS}

Preoperative and operative data are summarized in the table 1. At
discharge, all patients received optimal medical treatment.

Sensitivity and specificity of TV cutoffs for TR recurrence were 66\%
and 88\% for tricuspid annulus\selectlanguage{english}[?]35mm, 83\% and 42\% for CD\selectlanguage{english}[?]6.5mm, and
81\% and 34\% for tenting area\selectlanguage{english}[?]0.85cm\textsuperscript{2})

Five-year freedom from TR recurrence was 74+-3\%, significantly lower in
patients with residual TR (41+-8\% vs 81+-3\%, p\textless{}0.001).

\textbf{Patients with residual TR}

Fifty-four patients showed residual TR. In 22 (41\%) cases, the grade of
TR at follow up was mild-or-less, conversely, in 32 (59\%) cases, TR
remained moderate-or-more. Five (9.3\%) patients died after first month
with a 8-year survival of 86+-6\%.

\textbf{Patients without residual tricuspid regurgitation}

Recurrent TR after TA was recorded in 53 (14\%) cases; 5-year adjusted
freedom from TR recurrence was significantly lower in patients with
preoperative RV remodeling (75+-4\% vs 91+-3\%, p\textless{}0.001; Figure
1).

In 114 (31\%) patients RV was found remodeled at follow up; adjusted
5-year freedom from RV remodeling was 66+-3\%, significantly lower in
patients with preoperative RV remodeling (57+-4\% vs 79+-5\%,
p\textless{}0.001, Figure 2).

At multivariable analysis, similar risk factors were identified for TR
recurrence and RV remodeling: preoperative RV remodeling, preoperative
mild-or-moderate TR with TV remodeling, severe TR, preoperative
pulmonary pressure and functional MR (Tables 2-3).

Comparison between preoperative and follow up echocardiographic data are
summarized in the table 4.

Twenty-six patients died after discharge, 18 from cardiac or unknown
causes and 8 from non-cardiac causes. Eight-year survival was 88+-3\%.
Cox analysis with time-dependent variable confirmed TR recurrence and
late RV remodeling as risk factors for lower survival (Table 5, Figures
3-4).

\textbf{Surgery and late results}

No protective effect of either flexible band/ring (HR 1.06, 0.28-3.97)
or rigid ring (HR 1.99, 0.50-6.91) with respect to DeVega was found.

Similarly, late failure of MV surgery (HR 1.28, 0.78-3.78) did not
influence the outcome of TR.

\textbf{Etiology of MR}

The cohort of 369 patients were finally divided according to MR disease,
in functional MR (116 patients) and non-functional MR (253); the first
group showed significantly worse left ventricle but similar RV than the
second group (Table 6).

\textbf{Discussion}

This retrospective study confirms that TA besides left-sided valve
surgery has still suboptimal results, with residual TR of 13\%, within
the range reported in the literature (9-39\%)\textsuperscript{10-14}. In
our series, 20\% of cases experienced TR recurrence at mid-term, lower
than others (31-45\%)\textsuperscript{10,14,15}. However, the rate of
late TA failure increased significantly in patients discharged with
residual TR. Kuwaki et al\textsuperscript{11} reported an hazard ratio
of even 15.1\% TV reoperation in patients with residual TR.

In patients without residual TR at the discharge, preoperative severity
of TR and TV remodeling, preoperative RV remodeling, functional MR and
systolic pulmonary pressure were identified as risk factors for
moderate-or-more late TR.

As expected\textsuperscript{11,14-16}, preoperative severe TR was found
to be an important predictor for TR recurrence. Although TA can
effectively reduce annular dimension, it further increases chordal
tethering with aggravation of leaflet tenting as a consequence of
increased interpapillary muscle distance and incomplete leaflet closure
due to inward annulus displacement after TA, ultimately leading to TA
failure.

Nowadays surgery is indicated in patients with severe TR and should be
considered in patients with mild-or-moderate TR with a
TA\selectlanguage{english}[?]40m\textsuperscript{17}. However, besides TA dilatation, tethering
severity plays a key-role for TA durability. Fukuda et
al\textsuperscript{15} proposed a tenting height of 5.1 mm and a tenting
area\textgreater{}0.8 cm\textsuperscript{2} as predictors for TV
recurrence. In our study, a CD\selectlanguage{english}[?]6.5mm, tenting
area\selectlanguage{english}[?]0.85cm\textsuperscript{2} and a tricuspid annulus\selectlanguage{english}[?]35mm were
predictive for recurrent TR even in presence of moderate-or-less TR.
This result supports the rationale for performing prophylactic TA in
low-graded TR with TV remodeling, since TA does not increase operative
risk\textsuperscript{18}. Shiran et al\textsuperscript{19} suggested to
perform TA for low-graded TR and tricuspid annulus\selectlanguage{english}[?]35mm. We believe that
TA size alone cannot be used to identify patients who should receive
prophylactic TA, but tethering severity should also be considered.

The purpose of surgery should be to interfere with the mechanisms
leading to irreversible RV damage by correcting both left-sided lesions
(to reduce pulmonary pressure) and TR (to eliminate volume
overload)\textsuperscript{20,21}.

The main finding of this study is the strict correlation between the
evolution of TA and RV remodeling. Risk factors impairing late result of
TA are the same impairing late RV remodeling, demonstrating a
synergistic relationship between these two entities. Failure of TA
causes increased volume overload with possible RV dilatation and
dysfunction, which in turn begets TR. The patients with preoperative
severe-or-less TR with TA dilatation can show positive RV remodeling
after TA\textsuperscript{21}. However, in some cases, RV remodeling
after TA\textsuperscript{12} is not so positive as expected, likely due
to irreversible maladaptive RV hypertrophy/enlargement with reduced RV
contractility. RV enlargement can result in disproportionate dilatation
along the free wall to the septum minor axis and a more spherical RV
shape, which implies a greater displacement of the papillary
muscles\textsuperscript{22}. Yu and
coworkers\textsuperscript{22}demonstrated that patients undergoing TA
who had a larger RV mid-cavity diameter along with larger TV tethering
area, developed adverse events at 1-year follow up. So, TA may not be
able to approximate displaced papillary muscle to achieve an effective
TV closure.

Moreover, both late significant TR and RV remodeling were found to be
risk factors for lower survival. In a recent echocardiographic
analysis\textsuperscript{23}, 5-year survival was significantly worse in
patients presenting RV dilatation or dysfunction than normal RV.

How much preoperative pulmonary pressure can be improved by TA is still
debated. Chickwe et al\textsuperscript{24} analyzed results of 419
patients receiving TA along with MV repair, showing sPAP improved
significantly at discharge and follow-up. Conversely, Chen et
al\textsuperscript{25} demonstrated that 43\% of patients undergoing TA
had residual~PH; De Bonis et al\textsuperscript{26} reported 26\% of
patients has still higher sPAP at follow up. In patients having MV
surgery, residual PH is likely due to irreversible pulmonary vascular
remodeling, and this barrage can produce both RV remodeling and TR
recurrence over time\textsuperscript{27}.

In our experience, patients with FMR undergoing MV/ TV surgery showed
more dilated and dysfunctioning LV than no-FMR, with higher sPAP. The
underlying disease of FMR is both valvular and ventricular, so, despite
surgical correction of MV, LV remodeling may not improve. Higher
intraventricular end-diastolic pressure may persist after surgery, with
consequent high post-capillary pulmonary
pressure.\textsuperscript{26}Moreover, most of the effects of LV
contraction on the RV are mediated by the interventricular septum. In
presence of cardiomyopathy, septal twisting is reduced due to septal
damage, especially when pulmonary vascular resistances are increased.

The natural consequence is that RV remodeling may not improve, with
increasing of tethering forces on TV leaflets and the inability to coapt
despite TA.

Whether the surgical technique could influence TR recurrence remains
debated\textsuperscript{27-30} . In our experience, no difference was
observed according to the surgical strategy.

Patients with severe TR and dilated RV represent a challenging subgroup
where TA id not a reasonable treatment option. The clover
technique\textsuperscript{31} or anterior leaflet patch
augmentation\textsuperscript{32}, may be valuable alternatives. We
recently reported a strategy where the anterior and posterior leaflets
are almost entirely detached (50\% of the annulus) and a patch as large
as the full tricuspid orifice is inserted without
TA\textsuperscript{33}. It is however evident that there is no definite
solution yet to this problem, and perhaps it is time to think to a
prospective randomized study to find the best treatment option.

Limitations of the study

Firstly, it is retrospective, then, TR grading could be exposed to
operator's bias and was out of our control. Moreover, 3D
echocardiography was not used in our study population.

\textbf{Conclusions}

Prophylactic tricuspid TA should be encouraged among surgeons even
earlier than guidelines recommend, and decision-making for the treatment
of low-graded TR at the time of left-sided valve surgery should consider
not only annular size, but also tethering severity and RV remodeling. In
these cases, the surgical approach should not be limited to TA, but
surgeons should consider alternative techniques or prosthesis
implantation.

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\textbackslash{}sout

\textbf{Figure legends}

\textbf{Figure 1.} Adjusted freedom from tricuspid regurgitation (TR)
recurrence according to the presence (yellow-line) or absence
(blue-line) of preoperative right ventricular remodeling.

\textbf{Figure 2.} Adjusted freedom from late right ventricular (RV)
remodeling according to the presence (yellow-line) or absence
(blue-line) of preoperative right ventricular remodeling.

\textbf{Figure 3.} Adjusted survival according to the presence
(yellow-line) or absence (blue-line) of TR recurrence.

\textbf{Figure 4.} Adjusted survival according to the presence
(yellow-line) or absence (blue-line) of late RV remodeling.

Table 1. Preoperative and operative data according to residual or not
tricuspid regurgitation.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Overall N=423\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Non-residual TR N=369\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Residual TR N=54\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
p-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age (years)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
52\selectlanguage{ngerman}±16\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
52\selectlanguage{ngerman}±15\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
52\selectlanguage{ngerman}±17\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.887\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
BMI (Kg/m2)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28\selectlanguage{ngerman}±6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28\selectlanguage{ngerman}±6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28\selectlanguage{ngerman}±7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.513\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Female gender\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
256(61\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
218(59\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38(70\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.113\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Creatinine (mmol/L)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69(55-85)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69(55-85)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68(59-84)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.965\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Diabetes\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
163(39\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
140(38\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
23(43\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.512\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Rhythm status\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.107\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Sinus rhythm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
299(71\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
267(72\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
32(59\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Atrial fibrillation\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
122(28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
100(27\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
22(41\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Pacemaker\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2(1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2(1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
NYHA\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.311\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
I\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18(4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17(5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1(2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
II\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
66(16\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
61(17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9(9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
III\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
274(65\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
237(64\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
37(69\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
IV\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
65(15\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
54(15\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11(20\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Status\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.773\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Elective/Urgent\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
417(98\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
364(99\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
53(98\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Emergent\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6(2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5(1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1(2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MV disease\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.809\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Functional MR\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
130(31\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
116(31\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14(26\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Rheumatic\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
195(46\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
166(45\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29(54\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Organic non rheumatic\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
64(15\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57(15\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7(13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Myxomatous\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20(5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18(5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2(4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Prosthesis dehiscence\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14(3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12(3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2(4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEF (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48\selectlanguage{ngerman}±12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48\selectlanguage{ngerman}±12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48\selectlanguage{ngerman}±12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.810\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEDD (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
54\selectlanguage{ngerman}±9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
54\selectlanguage{ngerman}±9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
52\selectlanguage{ngerman}±8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.049\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVESD (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38\selectlanguage{ngerman}±9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38\selectlanguage{ngerman}±9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
36\selectlanguage{ngerman}±10\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.156\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEDV (ml(m\textsuperscript{2})\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
82\selectlanguage{ngerman}±30\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
82\selectlanguage{ngerman}±31\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
78\selectlanguage{ngerman}±25\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.242\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVESV (ml(m\textsuperscript{2})\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41\selectlanguage{ngerman}±24\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41\selectlanguage{ngerman}±25\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
37\selectlanguage{ngerman}±23\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.336\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TV annulus (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35\selectlanguage{ngerman}±4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35\selectlanguage{ngerman}±4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38\selectlanguage{ngerman}±3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]35mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
232(55\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
186(50\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
46(85\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CD (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.2\selectlanguage{ngerman}±1.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.1\selectlanguage{ngerman}±1.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.1\selectlanguage{ngerman}±1.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]6.5mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
81(19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
56(12\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25(46\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TV tenting area\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.06\selectlanguage{ngerman}±0.56\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.01\selectlanguage{ngerman}±0.53\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.31\selectlanguage{ngerman}±0.65\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.027\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]0.85cm\textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
109(26\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
82(22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27(50\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
sPAP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
53\selectlanguage{ngerman}±18\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
52\selectlanguage{ngerman}±18\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
55\selectlanguage{ngerman}±18\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.383\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TAPSE (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18\selectlanguage{ngerman}±6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18\selectlanguage{ngerman}±6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.009\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TDI S' (cm/s)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13\selectlanguage{ngerman}±4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13\selectlanguage{ngerman}±4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12\selectlanguage{ngerman}±4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.227\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RVBD (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RVMD (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
37\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
37\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
40\selectlanguage{ngerman}±5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
RV remodeling\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
258(61\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
250(56\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
50(93\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TR grade\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Mild\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
70(17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69(19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1(2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Moderate\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
232(55\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
212(57\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20(37\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Severe\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
121(28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
88(24\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
33(61\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
TV surgery\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.424\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
DeVega\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24(6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
21(6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3(6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Rigid Ring\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
76(18\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69(19\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7(13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Flexible ring/band\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
323(76\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
279(75\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
44(81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CABG\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
129(31\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
114(31\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15(28\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.642\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MV surgery\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.011\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MV repair\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
160(38\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
148(40\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15(22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
MV replacement\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
263(62\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
221(60\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42(78\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
AVR\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
89(21\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
82(22\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7(13\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.117\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
SVR\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
38(9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35(10\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3(6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.346\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Legend. BMI = body mass index, NYHA = New York Heart Association, MV =
mitral valve, MR = mitral regurgitation, LVEF = left ventricular
ejection fraction, LVEDD = left ventricular end-diastolic diameter,
LVESD = left ventricular end-systolic diameter, LVEDV = left ventricular
end-diastolic volume, LVESV = left ventricular end-systolic volume, TV =
tricuspid valve, CD = coaptation depth, sPAP = systolic pulmonary artery
pressure, TAPSE = tricuspid annular plane systolic excursion, TDI =
tissue Doppler imaging, RVBD = right ventricular basal diameter, RVMD =
right ventricular mid-cavity diameter, TR = tricuspid regurgitation,
CABG = coronary artery bypass grafting, AVR = aortic valve replacement,
SVR = surgical ventricular reconstruction.

\textbf{Table 2.} Risk factors for recurrent tricuspid regurgitation.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Model 1}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{HR}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{95\% CI}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pre sPAP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.013\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.008--1.027\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.042\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre RV remodeling*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{2.316}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{1.172--4.574}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{0.015}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Functional MR\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.880\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.046--3.376\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.034\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Model 2}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{HR}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{95\% CI}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pre sPAP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.013\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.009--1.029\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.041\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre mild or moderate TR (reference)} \textbf{without TV
apparatus remodeling}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Pre mild or moderate TR} \textbf{with TV apparatus
remodeling}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{8.545}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{2.562--28.495}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre severe TR}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{14.591}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{4.356--48.864}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Functional MR\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.206\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.209--4.024\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.009\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

HR, hazard ratio; CI, confidence interval; Pre, preoperative; sPAP,
systolic pulmonary artery pressure; RV, right ventricle; TR, tricuspid
regurgitation; TV, tricuspid valve; MR, mitral regurgitation.

\emph{C-statistic 0.75 (model 1); C-statistic 0.78 (model 2)}

\emph{*RV remodeling and TV remodeling are correlated}

\textbf{Table 3.} Risk factors for late right ventricular remodeling.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{Model 1}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{HR}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{95\% CI}\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pre sPAP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.009\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.005--1.018\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.048\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre RV remodeling*}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{2.551}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{1.616--4.024}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Functional MR\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.504\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.016--2.226\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.041\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Model 2}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{HR}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{95\% CI}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pre sPAP (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.010\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.002--1.019\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.045\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre mild or moderate TR (reference)} \textbf{without TV
apparatus remodeling}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Pre mild or moderate TR} \textbf{with TV apparatus
remodeling}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1.203}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{1.008--1.938}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.046}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{Pre severe TR}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{2.478}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{1.560--3.937}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{\textless{}0.001}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Functional MR\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.603\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1.081--2.380\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.019\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

HR, hazard ratio; CI, confidence interval; Pre, preoperative; RV, right
ventricle; TR, tricuspid regurgitation; TV, tricuspid valve;

MR, mitral regurgitation. \emph{C-statistic 0.75 (model 1); C-statistic
0.75 (model 2)}

\emph{*RV remodeling and TV remodeling are correlated}

Table 4. Comparison of echocardiographic data between preoperative and
follow up.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Preop 369 & Follow up 369 & p-value\tabularnewline
\midrule
\endhead
LVEF (\%) & 48\selectlanguage{ngerman}±12 & 47\selectlanguage{ngerman}±12 & 0.321\tabularnewline
LVEDD (mm) & 54\selectlanguage{ngerman}±8 & 50\selectlanguage{ngerman}±8 & \textless{}0.001\tabularnewline
LVESD (mm) & 38\selectlanguage{ngerman}±9 & 37\selectlanguage{ngerman}±10 & \textless{}0.001\tabularnewline
sPAP (mmHg) & 54\selectlanguage{ngerman}±18 & 43\selectlanguage{ngerman}±14 & \textless{}0.001\tabularnewline
TAPSE (mm) & 18\selectlanguage{ngerman}±6 & 20\selectlanguage{ngerman}±6 & \textless{}0.001\tabularnewline
TDI S' (cm/s) & 13\selectlanguage{ngerman}±4 & 14\selectlanguage{ngerman}±4 & \textless{}0.001\tabularnewline
RVBD (mm) & 42\selectlanguage{ngerman}±5 & 39\selectlanguage{ngerman}±5 & \textless{}0.001\tabularnewline
RVMD (mm) & 37\selectlanguage{ngerman}±5 & 34\selectlanguage{ngerman}±5 & \textless{}0.001\tabularnewline
RV remodeling & 208(56\%) & 114(31\%) & \textless{}0.001\tabularnewline
TR grade & & & \textless{}0.001\tabularnewline
No TR & 0 & 128(35\%) &\tabularnewline
Mild & 69(19\%) & 188(51\%) &\tabularnewline
Moderate & 212(56\%) & 41(11\%) &\tabularnewline
Severe & 88(24\%) & 12(3\%) &\tabularnewline
\bottomrule
\end{longtable}

Legend. LVEF=left ventricular ejection fraction, LVEDD=left ventricular
end-diastolic diameter, LVESD=left ventricular end-systolic diameter,
sPAP=systolic pulmonary artery pressure, TAPSE=tricuspid annular plane
systolic excursion, TDI=tissue Doppler imaging, RVBD=right ventricular
basal diameter, RVMD=right ventricular mid-cavity diameter, TR=tricuspid
regurgitation.

\textbf{Table 5.} Cox with time-dependent variable: Risk factors for
late mortality.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Model 1} & \textbf{HR} & \textbf{95\% CI} &
\textbf{p}\tabularnewline
\midrule
\endhead
Pre creatinine (mmol/l) & 1.002 & 1.001-1.005 & 0.024\tabularnewline
\textbf{Late TR[?]2+} & \textbf{3.106} & \textbf{1.519-6.349} &
\textbf{0.002}\tabularnewline
Functional MR & 4.497 & 2.101-9.625 & \textless{}0.001\tabularnewline
LVEF (\%) & 0.9718 & 0.938-0.992 & 0.044\tabularnewline
\textbf{Model 2} & \textbf{HR} & \textbf{95\% CI} &
\textbf{p}\tabularnewline
Pre creatinine (mmol/l) & 1.002 & 1.001-1.004 & 0.006\tabularnewline
\textbf{Late RV remodeling} & \textbf{6.468} & \textbf{3.884-10.773} &
\textbf{0.001}\tabularnewline
Functional MR & 1.819 & 1.134-2.918 & 0.013\tabularnewline
Diabetes & 1.808 & 1.131-2.890 & 0.013\tabularnewline
\bottomrule
\end{longtable}

HR, hazard ratio; CI, confidence interval; Pre, preoperative; RV, right
ventricle; TR, tricuspid regurgitation; TV, tricuspid valve;

MR, mitral regurgitation. \emph{C-statistic 0.84 (model 1); C-statistic
0.80 (model 2)}

Table 6. Comparison of preoperative echocardiographic data between
functional and non-functional mitral regurgitation.\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& FMR n = 116 & No-FMR n =253 & p-value\tabularnewline
\midrule
\endhead
LVEF (\%) & 35\selectlanguage{ngerman}±12 & 53\selectlanguage{ngerman}±8 & \textless{}0.001\tabularnewline
LVEDD (mm) & 58\selectlanguage{ngerman}±9 & 53\selectlanguage{ngerman}±8 & \textless{}0.001\tabularnewline
LVESD (mm) & 44\selectlanguage{ngerman}±9 & 36\selectlanguage{ngerman}±8 & \textless{}0.001\tabularnewline
sPAP (mmHg) & 57\selectlanguage{ngerman}±16 & 52\selectlanguage{ngerman}±19 & 0.035\tabularnewline
TAPSE (mm) & 18\selectlanguage{ngerman}±6 & 18\selectlanguage{ngerman}±6 & 0.257\tabularnewline
TDI S' (cm/s) & 13\selectlanguage{ngerman}±4 & 13\selectlanguage{ngerman}±4 & 0.328\tabularnewline
RVBD (mm) & 42\selectlanguage{ngerman}±5 & 42\selectlanguage{ngerman}±5 & 0.716\tabularnewline
RVMD (mm) & 37\selectlanguage{ngerman}±5 & 37\selectlanguage{ngerman}±6 & 0.956\tabularnewline
RV remodeling & 67 (58\%) & 141 (56\%) & 0.715\tabularnewline
TV remodeling & 61 (53\%) & 148 (59\%) & 0.287\tabularnewline
TR grade & & & 0.011\tabularnewline
Mild & 28 (24\%) & 41 (16\%) &\tabularnewline
Moderate & 71 (61\%) & 141 (56\%) &\tabularnewline
Severe & 17 (15\%) & 71 (28\%) &\tabularnewline
\bottomrule
\end{longtable}

Legend. LVEF = left ventricular ejection fraction, LVEDD = left
ventricular end-diastolic diameter, LVESD = left ventricular
end-systolic diameter, sPAP = systolic pulmonary artery pressure, TAPSE
= tricuspid annular plane systolic excursion, TDI = tissue Doppler
imaging, RVBD = right ventricular basal diameter, RVMD = right
ventricular mid-cavity diameter, TR = tricuspid regurgitation.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

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\selectlanguage{english}
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