When To Consider Tricuspid Valve Repair

V. Jeevanandam, M.D.

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The “ignored” valve

• Rarely affected in isolation

• Manifestations are extra-cardiac – Peripheral edema – Liver congestion… ascites – Renal dysfunction by decreasing transrenal gradient

• Low pressure so hard to evaluate; volume dependent

• TR associated with poor prognosis in: – Primary: endocarditis, iatrogenic, rheumatic, carcinoid, myxomatous

– Functional : left sided lesions, cardiomyopathy, pulmonary HTN

– LVADs

– Transplantation

• Does repairing the TR make a difference?

• Three leaflets – Ant > post > septal

• Three clefts – do not extend to annulus

• Annulus not a fixed structure – Anterior and posterior

attached to RV free wall – Dynamic with change in

orifice area during cardiac cycle

– Saddle shaped to decrease leaflet stress

Fibrous skeleton - closed AV valves

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TV abnormalities – primary

- Symptomatic

- Preserved RV function:

low RVEDP

- Low PA pressures

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TV abnormalities – primary • Stenosis

– Rheumatic

– Carcinoid

– Appetite suppressing drugs

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TV abnormalities – primary

• Regurgitation

– Endocarditis • IVDA

• Hemodialysis

• Pacing leads

– Trauma

– Myxomatous

– Post-infarction

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TV abnormalities – primary

• Regurgitation

– Iatrogenic • Pacemakers and ICD

• Transplant biopsies

• TIPPS catheters

• In-dwelling lines

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3D Echo

Post Ant

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Postoperative 3DE

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DeVega

annuloplasty

and tricuspid

valve annulus

Ruptured chordae

Septal

leaflet

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PTFE chordal

reconstruction

*

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TV abnormalities – functional

• Annular dilation – Perimeter increase 100-120 to >150mm – Diameter >40mm – Asymmetric

• Basis of repair

• RV dysfunction – Pressure, volume overload

• Pulmonary hypertension • Left sided lesions

– Infarction – LVAD placement

• Prognosis depends on RV function

• Treatment: reduction annuloplasty – Suture DeVega – Rigid ring

2D ECHO annulus dilation

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3D for TC annulus dilation

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Functional TR: TVA concomitant with MV surgery • Guidelines •

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TVA concomitant with MV Surgery

• Why? Raja, Dreyfus. Basis for Intervention on Functional TR. Semin Thoracic Surg 22:79-83

• TR does not improve after MV procedure – especially if annulus dilated >4cm

• Actually worsens

• Survival benefit not proven

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Functional TR: TVA reoperation after MV Surgery

• Kim, Kwon, Kim, et al. Determinants of surgical outcome in patients with isolated TR. Circulation 2009; 120:1672-8

• 61 patients with TR after left sided procedure

• Favors – Concomitant procedure

– Earlier TVA before cardiac deterioration – marker for worsening RV

NYHA class % patients Event free 1 yr Event free 2 yr

II 34 95 90

III, IV 66 73 68

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TR repair: Concomitant with cfLVAD

• Saeed, Kidambi, Shalli, McGee, et al. TV repair with LVAD: is it warranted? JHLT 2011;30:530

– 72 LVADs, 42 > 3+ TR, 8 repaired / 34 no repair

– No benefit from TVR

– TVR : longer CPB, more blood, higher BUN / crt.

– Small study, selection bias

• Maltais, Topilsky, Park, et al. Surgical treatment of TR promotes early reverse remodeling in patients with cfLVAD. JTCVS 2012;143:1370

– 83 HMII, 37 severe TR (32 repair, 5 replacement)

– TR group worse – more TR vena contracta, more RV dysfunction (RVEDA), higher RA pressure, higher Kormos score, more IABP

– 30 days in TVR group – TR better than in LVAD only group (-50.2% vs 18.6% ); more RVEDA reduction

– Survival and RVF similar although TR group sicker

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TR repair: Concomitant with cfLVAD • Piacentino, Rogers, Milano, et al. Utility of concomitant TV procedures

for patients undergoing cfLVADs. JTCVS 2012;144:1217-21

– 200 consecutive LVADs; 61 significant TR (3 or 4+); 33 cfLVAD + TVP with 28 just receiving cfLVAD

• Summary: for cfLVAD, repairing TV improves RV function an decreases TR but without statistically significant survival benefit

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Prophylactic TVA with heart transplantation

• Significant TR after HT reported from 10-60%.

– Depends on bicaval/total vs biatrial; RV function; pulmonary hypertension

– TR associated with worse survival

• Jeevanandam, et al. Prophylactic TV DeVega Annuloplasty during heart transplantation. Ann Thor Surg 2004 78(3):759-66 – Randomized controlled trial – bOHT vs. bOHT + TVA; 30 patients in each arm

– Donor and recipient demographics similar

– Followed out to 6 years

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Results: severity of TR Group Avg. ≤ 1 2 ≥ 3 % > 2

Intra-operative A 1.1 ± 1.0 21 5 4 30.0%B .33 ± .38 30 0 0 0.0%

p=0.01 p=0.01

1 Week A 0.6 ± 0.9 24 2 1 11.1%B 0.4 ± 0.6 28 2 0 6.7%

ns ns

1 Month A 1.0 ± 0.9 20 4 2 23.1%B 0.3 ± 0.7 28 1 1 6.7%

p=0.006 p=0.05

1 Year A 1.3 ± 1.0 17 7 2 34.6%B 0.2 ± 0.3 27 0 0 0.0%

p=0.01 p=0.02

6 Years A 1.5 ± 1.3 14 2 6 36.4%B 0.5 ± 0.4 22 0 0 0.0%

p=0.01 p=0.02Mann Whitney U test

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Is there a correlation between >2+ TR and death?

Survival Functions

MO_ALIVE

120100806040200-20

Cu

m S

urv

iva

l

1.1

1.0

.9

.8

.7

.6

.5

.4

TR2

1.00

1.00-censored

.00

.00-censored

Yes: log rank p=0.005

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Results: renal function Group BUN Crt dCrt

Pre-operative A 22.3 ± 11.5 1.02 ± .3B 26.8 ± 15.6 1.34 ± .7

ns p=0.058

1 Week A 45.6 ± 28.9 1.21 ± .6 .2 ± .6B 40.2 ± 29.6 1.5 ± 1.3 .2 ± 1.5

ns ns ns

1 Month A 33.6 ± 12.4 1.2 ± .6 .2 ± .7B 33.2 ± 12 1.3 ± .5 0 ± .8

ns ns ns

1 Year A 42.5 ± 16.5 2.3 ± 1.3 1.3 ± .9B 37.7 ± 15 2.2 ± 1 1.1 ± .9

ns ns p=0.061

6 Years A 41.0 ± 14.4 2.9 ± 2.0 2.0 ± 2.0B 32.3 ± 12.1 1.8 ± 0.7 0.7 ± .8

ns p=0.04 p=0.02

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Is there a correlation between TR >2+ and creatinine >2.5?

AVG_TR

543210-1

CR

EA

T10

8

6

4

2

0

DEVEGA

1.00

.00

Yes: Fisher exact p=0.002

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Summary

• Increased appreciation of tricuspid valve – Regurgitation and chronic high CVP associated with decreased

survival – Renal / hepatic dysfunction, edema, ascites

• Repair technique: – rigid annuloplasty most durable – Suture reasonable for prophylactic or normal PA pressures

• Primary TV repair indicated if severe and symptomatic (Class IIa, evidence C)

• Functional TR (>3+) or annulus greater than 4cm – With MV surgery (class I, evidence B) – Isolated, after MV surgery, no PulmHTN (ESC – class IIaC). NYHA 3, 4

poor 2 year event free survival – cfLVAD: decrease RV failure, better RV remodeling, no survival benefit

• TVA with HT – survival and renal benefit.

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Papillary Muscle and Chordae

• Marginal chords attached to free margin – Prevent regurgitation

• Basal chords attached to body – Maintain structure of RV

• Ant, post papillary muscle and septal band

ECHO - Normal tricuspid function

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Surgeons view