Tricuspid Valve Surgery - Peninsula

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SurgeryFebruary 8, 2020

Tricuspid Valve Surgery

Jeffrey G. Gaca, MD

Associate Professor of Surgery

Division of Cardiothoracic Surgery

Duke University Medical Center

All Rights Reserved, Duke Medicine 2007

Financial Disclosures

• None

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Tricuspid Valve – Anatomy

• The Tricuspid Valve complex consists of the annulus, leaflets, right ventricle, papillary muscles, and chordae tendinae.

• The tricuspid annulus separates the right ventricle from the right atrium


Tricuspid Valve Anatomy

Important surrounding structures include:1) AV node2) Right coronary

artery3) Coronary Sinus4) Membranous

Septum5) Aortic Valve6) Triangle of Koch

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Tricuspid Valve - Pathophysiology

Tricuspid Stenosis

1) Rheumatic Heart Disease

2) Congenital – Ebstein’s Anomaly

3) Metabolic or Enzymatic diseases (Fabry’s or Whipple’s Diseases)

4) Endocarditis

5) Right atrial or ventricular tumors

• Tricuspid Regurgitation

1) Functional

2) Primary – Congenital (Ebstein’s) or Endocarditis



• Primary (8-10%)

1) Endocarditis

2) Congenital (Ebstein’s)

3) Pacemaker / Defibrillator Leads

4) Trauma

5) Radiation

6) Myxomatous Degeneration (rare)

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• Secondary – approximately 90% of cases

1) Left sided heart disease (MV stenosis / regurgitation)

2) Right ventricular dysfunction

3) Chronic Atrial Fibrillation


Tricuspid Regurgitation (TR)

• Associated with increased morbidity and mortality

• Functional TR is most common form of TR in Western countries.

• This a dynamic process that is dependent on many factors : RV performance, pulmonary hypertension, heart loading conditions, heart rhythm.

• Annular dilation and leaflet tethering are the 2 fundamental mechanisms responsible for TR.

• Only a 40% change in TV annular diameter can cause severe TR whereas a 75% change in MV annular diameter is required to cause severe MR.

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Tricuspid Regurgitation

The tricuspid annulus dilates outward toward the RV free wall.


Tricuspid Regurgitation (TR)

• Right ventricular pressure/volume overload leads to ventricular remodeling and annular dilation and leaflet tethering.

• The is most commonly caused by pulmonary hypertension.

• As RV function deteriorates, leaflet tethering worsens leading to increasing degrees of TR.

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Pulmonary Hypertension (PH) and Pulmonary Vascular Resistance (PVR)

• PH is frequently associated with TR.

• Long standing PH and can lead to decreases in RV function.


Tricuspid Regurgitation - Presentation

The majority of patients are asymptomatic

Severe TR is associated with

1) lower extremity edema

2) fatigue

3) ascites

4) congestive hepatopathy

5) atrial fibrillation

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• Study followed 353 patients with isolated tricuspid regurgitation.

• Severe tricuspid regurgitation was defined as either an effective regurgitant orifice (ERO) as greater than 40 mm2 (68 patients) or qualitatively as severe (76 patients.

• Outcomes were compared between the groups with ERO > 40 mm2 and ERO < 40 mm2


An ERO > 40 mm2 was associated with an increased mortality

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• The 10 year mortality from isolated severe TR was significantly higher than the trivial to moderate TR group.

• Freedom from cardiac events was lower in the isolated TR group independent of all characteristics, RV size or function, comorbidity, or pulmonary pressure.

• ERO measurement is a powerful independent predictor of outcome in isolated severe TR.

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• Medical therapy

1) diuretics

2) pulmonary vasodilators



• 20-30% of patients presenting with left sided valvulardisease present with significant tricuspid regurgitation

• Both European and AHA guidelines concur that severe TR should be addressed at the time of left sided valvular surgery.

• Evidence is growing that addressing moderate TR at the time of left sided valve surgery is beneficial and improves long term RV remodeling

• There are no guideline recommendations for the surgical treatment of isolated TR

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Tricuspid Valve Surgery

• Repair

• Replacement

Bioprosthetic

Mechanical

Transcatheter

Any strategy to address TR must take into account the underlying pathology!

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Tricuspid Valve Repair

• Goal – restoration of leaflet coaptation

• Techniques of Repair

DeVega annuloplasty

Ring annuloplasty

Flexible or Rigid ring?


Kay Annuloplasty

• Introduced in 1965

• Suture exclusion of the posterior leaflet of the tricuspid valve.

• Achieves functional “bicuspidization” of the tricuspid valve.

• Largely unused today.

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DeVega Annuloplasty

• Introduced in 1972.

• Uses a running circumferential suture to reduce the size of the tricuspid annulus.

• It was largely abandoned after the introduction annuoplasty rings

• Use today is limited to children with significant growth potential.


Ring annuloplasty

• Most commonly used surgical treatment of severe tricuspid regurgitation in use today.

• Partial rings address annular dilation and restore adequate zone of coaptation.

• Effectiveness of this technique is limited in cases of severe leaflet tethering

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Tricuspid Annuloplasty

Recently rings designed specifically for the tricuspid valve have come to market.


Triscuspid Annuloplasty

Rings designed specifically to treat the tricuspid valve.

Tricuspid rings have flexible and semi rigid sections to address the annular dilation.

The rings are incomplete to avoid injury to conduction system.

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• Analyzed data from over 28,000 inpatient admissions for tricuspid regurgitation.

• Overall operative mortality was 10.6%

• Isolated tricuspid surgery accounted for only 20% of all surgeries

• Hospital mortality for tricuspid replacement (16.1%) was higher than tricuspid repair (10.1%) p<0.0001

• The presence of significant liver disease was associated with a significantly higher operative mortality (22.9%) compared to no liver disease (9.4%) p<.0001.


• Overall operative mortality has generally decreased over time.

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• Utilized the MELD score to predict operative mortality after TV surgery.

• MELD – a validated scoring system of liver dysfunction used to predict morbidity and mortality after liver transplantation.

• Patients undergoing TV surgery were stratified into four groups by MELD and the outcomes from TV surgery analyzed.

• In addition, a Clinical Risk Score (CRS) was established to predict the operative mortality from TV surgery.


MELD score in TV surgery

Operative mortality increased with increasing MELD score

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• Increasing CRS resulted in a predictable increase in operative morbidity and mortality


• Observational study of 2556 patients in the Cleveland Clinic Database with severe TR.

• Only 534 (10.3%) of those patients underwent surgery for severe TR.

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• Patients who underwent TV surgery had better survival (62%) than those who received medical management (35%) at 38 months (p<0.0001)


Tricuspid Regurgitation – What we know….

• The presence of TR is associated with decreased survival.

• TV surgery is associated with a substantial operative mortality (approximately 10%)

• Patients with severe TR who receive surgery have a better survival than medical management.

• Significant liver disease (MELD) and RV dysfunction is a predictor poor outcomes after surgery

• Therefore….How do we select patients for high risk TV surgery ?

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Transcatheter Tricuspid Valve Interventions

• Multiple devices are in development.

• Most were initially developed for the mitral valve and have been adapted to the tricuspid valve.

• They either address coaptation or annular dilation.

• All are in early stages of development


Prospective multicenter of a transcatheter edge to edge tricuspid repair device.

85 patients underwent the procedure and 30 day and 6 month outcomes were reported.

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Delivery was successful in all patients. At least one grade reduction in TR was achieved in 91% of patients


Transcatheter Valve in Valve Tricuspid Replacement

• Can only be performed in patients with previously placed bioprosthetic valves.

• Cannot be reliably performed in the patients with previously placed tricuspid rings.

• Uses a TAVR device to implant in the tricuspid bioprosthesis.

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Case Scenario

• 64 year old woman underwent an orthotopic heart transplant in January 4, 2014.

• Immediately postoperatively, she developed RV dysfunction and severe TR in the transplanted heart.

• On January 21, 2014 she underwent TV replacement with 29 mm Medtronic Mosaic bioprosthetic valve.

• She developed severe bioprosthetic tricuspid valve stenosis.


A 29 mm SAPIEN 3 Transcatheter valve was deployed in the tricuspid prosthesis via the right common femoral vein.

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Tricuspid Valve Endocarditis

• Accounts for only 15% of infective endocarditis.

• However, its incidence is on the rise due to rise in illegal drug use (opoid epidemic)

• Medical therapy for TV endocarditis is very effective with an in-hospital mortality of 5%

• The increase in implantable devices such as pacemakers, defibrillators, and indwelling central lines also contributes to the increase in TV endocarditis.


• This study analyzed 910 operations for TV infective endocarditis between 2002 and 2009.

• Overall operative mortality as 7.3%

• Patients with treated endocarditis had lower mortality and complication rates compared to active endocarditis.

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TV Endocarditis – Surgical Options

• Repair

• Replacement

• Valvectomy – advocated by Arbulu


TV Endocarditis – Grow a new valve?

• Tricuspid valve reconstruction.

• Decellularized porcine small intestine submucosa that serves as scaffold for native tissue ingrowth.

• The native valve is excised and three patches are sewn into the tricuspid annulus to mimic the embryologic pattern of native tricuspid valve development.

• Early stages of clinical trials now

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Conclusions

• The presence of TR is marker of increased risk of mortality.

• Surgery for TR remains high risk due to co-morbid conditions “Canary in the coal mine”

• Deciding who will benefit from tricuspid intervention is the most difficult aspect of taking care of these patients

• Newer technology will drive continued innovation in the field.


Thank you!

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Tricuspid Valve Surgery - Peninsula