Anterior papillary muscle septalization associated with annuloplasty as a new approach to treat functional tricuspid regurgitation

Jean-Paul Couetil, MDHenri Mondor Hospital, Creteil, France

Tricuspid Valve: A complex anatomy and pathophysiology

• Tricuspid anatomy - Tricuspid annulus - Subvalvular apparatus (septum + RV free wall) - Tricuspid leaflets

• Mecanism of FTR

- Tricuspid annular dilatation - True prolapsing leaflet area - PMs displacement (RV remodling: conical spherical/elliptical)

PathophysTopilsky et al.iology of Functional TR

Left heart diseaseLeft heart disease

idiopathic Atrial fibrillationId-FTR

idiopathic Atrial fibrillationId-FTR

RA dysfunction/dilationRA dysfunction/dilation

Tricuspid Annular dilatationTricuspid regurgitation

Tricuspid Annular dilatationTricuspid regurgitation

Pulmonary hypertensionPHTN-FTR

Pulmonary hypertensionPHTN-FTR

RV dysfunction/dilationRV dysfunction/dilation

Pathophysiology of Functional TR ( 2 Populations)(Topilsky et al.Circ Cardiovasc Imaging, 2012)

No Left heart diseaseNo Left heart disease

Annuloplasty: The treatment of choice to cure FTR?

Prevalence of 3+/4+ TR at 5 yearsn=2’277 patients

Navia, et al. Surgical Management of Secondary Tricuspid Valve Regurgitation. J Thorac Cardiovasc Surg 2010: 1-10

Recu

rren

t TR

High incidence of recurrent FTR

Why do we have recurrent TR?Residual tricuspid regurgitation early after tricuspid valve annuloplasty

J Am Soc Echocardiogr 2007;20: 1236-1242

Apical four-chamber view demonstrating techniques used to measure TV deformations

What is the state-of-the Art to prevent from recurrent TR?

Tricuspid Leaflet Augmentation- Prof. Dreyfus

Clover Technique- Prof. Alfieri

These techniques Address TR, but are not a pathophysiological approach

Areas to Treat

Septalization of APM + annuloplasty to reverse the physiopatological FTR mecanism?

- Tricuspid valve tethering causing tenting, as a result of outward displacement of PMs in the dilated RV has been reported as a factor decreases the durability of TAP in 12 to 30 % of patients (Fukuda et al. Circulation. 2005; 111:975)

- Supported by in vitro study revealing that tricuspid annular dilatation and PMs displacement independently causeTR (Spinner et al. Circulation 2011;124:920)

- Valvular changes are linked to specific RV changes, largest basal dilatation, and normal length (RV conical deformation) in the id-FTR versus longest RV elliptical deformation/spherical deformation in PHTN-FTR (Topilsky et al. CIR Cardiovasc Imaging. 2012 5(3):314)

Rationale

Principles

1) - Based on the new insights of the complex pathophysiology of the FTR

2) - and Successful technique to relocate and reposition PMs in FMR to reduce mitral valve tenting and leaflets tethering

3) - This involves a septalisation of the base of the tricuspid anterior (posterior) papillary muscle

What is the septalization principle?

Functional Tricuspid Regurgitation

Surgical Remodeling of right ventricule

Area to Treat

To reposition the APMTo reallign the subvalvular apparatus In one plane

What is the septalization goal? 1)Treat the tentinga)Reduce AB diameter-Bring the tip of APMCloser to annular plane-Bring the tip of APM closer to the septum

2) Remodle the RVa)Reduce RV longitudinalb) And RV transversal diameters

How works the septalization +annuloplasty to reverse the mechanism of FTR?FTR Annuloplasty + APM-S

RV remodling

APM repositioning

• Surgical Technique of APM-S

2 pledget-reinforced 4/0 gore-Tex mattress sutures are passed through the base of the anterior papillary muscle close to its free wall insertion . The APM is brought to the septum and the sutures deeply anchored to the septum and firmly attached and tied

Surgical Technique of APM-S

Video1.5 MN

Surgical correction of the tenting (APM-S + Annuloplasty) and of local leaflets prolapse areas (Neo-Chords)

No APM-S = persistent tenting persistent central leak

APM-S: good coaptationNo more leak

Patients Characteristics

1/ Study Population :

– 48 patients ( men 21 ; mean age 63 ± 16 )– Prior cardiac surgery: n=12 ( 9 redux, 2 tridux, 1 quadridux)

– NYHA IV : n=23 48%III : n=19 40%II : n=5 10%I : n=1 2%

• Methods1/ Population:Study period was from April 2011 to september 2012Patients referred for tricuspid valve repair according to ESC guidelines

Guidelines on the managementof valvular heart disease

Vahanian et al., Eur Heart J 2007

3/ Echocardiographic Measurements

- 2-D TTE standard manner before and after surgery (Vivid7 GE)

RVED, RVES,RV fractional area change - 4 chamber view: SL-TV annular diameters, tenting height and area - TR severity assessed by color doppler imaging - TEE per operative before and after procedure - Follow-up TTE at 2, 6 and 12 months

Patients Characteristics

Pre-op Echo assessment

TTE Apical 4-chamber viewTenting height, Doppler imaging

(video clip)

3/ Surgery

– Anterior Papillary Muscle Septalisation (APM-S) associated with tricuspid ring implantation (Physio-ring size 26 to 34 mm)

– Associated procedures:• Mitral valve repair n=24 50%• Mitral valve replacement n=8 17%• Aortic valve replacement n=6 13%• Yacoub intervention n=1 2%• Coronary artery bypass grafting n=4 8%• Surgical ablation of atrial fibrillation n=4 8%• Ventricular septal defect closure n=2 4%

– (1 post STEMI, 1 congenital) – Extracorporeal duration : 118 ± 37 minutes – Aortic clamping duration: 97 ± 27 minutes

Patients Characteristics

Per operative TEE

1) Before procedure - Mitral stenosis - Severe FTR: Tenting height˃ 1.6 cm RV Dilatation

2) After procedure - MVR replacement - Surgical RV remodling - Annuloplasty - APM-S

(2 video clips)

4/ Postoperative results

– Death < 30 days : n=2 (1 mesenteric ischemia, 1 septic shock)– TTE at the last follow-up: Incidence of tricuspid regurgitation

IV : n=0III : n=1 2%

II : n= 5 10%0-I : n = 42 88%

98%

Summary/Conclusion

- TV is a less and less neglected valve - Recent new insights highlighted a complex

physiopathology of FTR which is better understood

Persisting issues: - Leaflets tenting correction - Post-OP Persistent and reccurent FTR - accurate per op assessment (echo and surgical)

Conclusion

APM-S + annuloplasty approach allows to/is 1) Correct the tenting 2) Remodle the RV 3) Decrease the incidence of early Post-OP Persistent and reccurent FTR 4) Reliable and reproducible technique 5) Preliminary results, needs to be confirmed