When to consider tricuspid valve repair

1. 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?

3. • 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
PostAnt

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10. Postoperative 3DE
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11. DeVega
annuloplasty
and tricuspid
valve annulus
Ruptured chordae
Septal
leaflet
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12. 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

15. 2D ECHO annulus dilation
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16. 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=0.02
Mann Whitney U test

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Is there a correlation between >2+ TR and
death?
Survival Functions
MO_ALIVE
120100806040200-20
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 ± .3
B 26.8 ± 15.6 1.34 ± .7
ns p=0.058
1 Week A 45.6 ± 28.9 1.21 ± .6 .2 ± .6
B 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 ± .7
B 33.2 ± 12 1.3 ± .5 0 ± .8
ns ns ns
1 Year A 42.5 ± 16.5 2.3 ± 1.3 1.3 ± .9
B 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 ± 2.0
B 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
CREAT 10
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

31. ECHO - Normal tricuspid
function
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Surgeons view