What are the indications for Tricuspid valve repair during LVAD Implant RANJIT JOHN, MD UNIVERSITY OF MINNESOTA

Size: px

Start display at page:

Download "What are the indications for Tricuspid valve repair during LVAD Implant RANJIT JOHN, MD UNIVERSITY OF MINNESOTA"

Aubrey Sanders
5 years ago
Views:

1 What are the indications for Tricuspid valve repair during LVAD Implant RANJIT JOHN, MD UNIVERSITY OF MINNESOTA

2 Contraindications for LVAD Lack of social support system Nonreversible end organ failure (dialysis, e.g.) Severe RV failure (MCS may still be an option) No data on BSA < 1.3 m² Limited data on pediatric patients Inability to tolerate anticoagulation - relative Unwilling to accept blood products Pregnancy Aortic insufficiency must be addressed

3 Contraindications Lack of social support system Nonreversible end organ failure (dialysis, e.g.) Severe RV failure (MCS may still be an option) No data on BSA < 1.3 m² Limited data on pediatric patients Inability to tolerate anticoagulation - relative Unwilling to accept blood products Pregnancy Aortic insufficiency must be addressed

4 The RV RV failure after LVAD is a HUGE risk factor for adverse outcome Evaluating RV function is challenging Echo usually looks terrible RV failure risk models Role of RHC

5 Predicting RV Failure After VAD CVP/PCWP ratio 0.63, preop ventilator, BUN>39 mg/dl Michigan RV failure risk score (vasopressor, AST 80, bilirubin 2, creatinine 2.3) Preoperative IABP, elevated PVR, DT indication Age, ascites, bilirubin, INTERMACS 1 Severe TR, Tricuspid annular motion <7.5 mm Right-to-left ventricular end-diastolic diameter >0.72 Procalcitonin, neopterin, NTproBNP, big endothelin-1 Low RVSWI Kormos RL et al, JTCVS 2010 Matthews JC et al, JACC 2008 Drakos SG et al, Am J Cardiol 2010 Holman WL et al, JHLT 2009 Puwanant S et al, JHLT 2008 Kukucka M et al, JHLT 2011 Hennig F et al, Gen TCVS 2011 Fitzpatrick JR 3 rd et al, JHLT 2008

6 Clinical vignette 51 year old woman with history of diffuse large B-cell lymphoma in 2007, treated with adriamycin + XRT in remission Heart failure treated with standard medical therapy, CRT-D Progressive intolerance of medical therapy, cannot climb any stairs or walk a block

7 Clinical vignette Medical therapy Metoprolol succinate 12.5 mg BID Losartan 12.5 mg daily Digoxin mg daily Spironolactone 12.5 mg daily Torsemide 20 mg BID Cardiopulmonary exercise Peak VO 2 8 ml/kg/min, VE/VCO 2 54 Right heart catheterization HR 104, BP 114/70 Mean RA 26, PA 52/30, PCWP 30, CI 0.8 (MvO 2 25%) After optimization: RA 10, PA 46/28, PCWP 22, CI 1.5

8 Predictors in our patient? CVP/PCWP ratio: 10/15 (0.66) Michigan RV risk score: (No presser, AST 26, Bilirubin 1.1, Creatinine 1.1) - LOW TAPSE? Severe TR

9 Implant HeartMate II implanted uneventfully Tricuspid valve repair Hypotensive, not tolerating milrinone CVP 15-17, PA 36/20, CI HM2: 8600, Flow L, PI 3.2, Power 4.4 ino initiated at 20 ppm Milrinone initiated IABP left for until POD 4

10 Follow-up Removed IABP Weaned ino, started sildenafil Milrinone and digoxin Failed attempt to decrease milrinone plan slow wean Discharge to rehab

11 Managing Valvular Heart Disease Issue Aortic insufficiency Possible Solution and Comments AI > moderate degree must be corrected. Aortic valve leaflets can be partially over sewn or the valve can be replaced with a bioprosthetic valve. The amount of post-operative AI may be underestimated preoperatively due to high LV filling pressures. When LV pressures decrease greatly, AI must be reassessed. Mitral regurgitation Mitral stenosis Tricuspid insufficiency Generally does not require repair. Mitral stenosis to a moderate degree or greater must be corrected with MV replacement with a bioprosthetic valve. Moderate to severe TR should be considered for repair to optimize right ventricular function. Especially important for patients with pulmonary hypertension. Tricuspid valve repair can be performed using annuloplasty repair (a ring or DeVega technique). Clinical Management of Continuous-flow LVADs JHLT 2010: 1-39.

12 Tricuspid Regurgitation J Thorac Cardiovasc Surg 2011; 1-7 Ann Thorac Surg 2011;92:

13 Tricuspid Regurgitation

14 Tricuspid Regurgitation

15 Tricuspid Regurgitation Parameter Pre-LVAD Post-LVAD p-value TR 2.5±1.1 (Mild-Mod) 2.0±1.1 (Mild) Tricuspid Annular Motion, mm * 11.7± ±2.5 <0.005 RAP, mm Hg * 13.7± ±5.6 <0.001 RVSW, ml*mm Hg * RVSWI, ml*mm Hg/m 2 * 1105 ± ± ± ± MPAP, mm Hg * 37.4± ±7.1 <0.001 PVR, Wood U * 3.7± ±0.8 <0.001 TPG, mm Hg * 12.7± ±3.2 <0.001 PCWP, mm Hg * 24.5± ±6.2 <0.001 CO, L/min * 3.8± ±1.3 <0.001 CI, L/min/m 2 * 1.9± ±0.5 <0.001 Lee et al, JHLT 2010 Lee S et al. JHLT 2010;29:

16 Lee S et al. Lee JHLT et 2010;29: al, JHLT 2012 Tricuspid Regurgitation

17 Piacentino et al, JTCVS 2012

18 Tricuspid valve procedures with LVAD 61 out of 200 CF LVAD patients had significant TR 33 underwent TVP Piacentino et al, JTCVS 2012

19 Piacentino et al, JTCVS 2012

20 Piacentino et al, JTCVS 2012 POST OP RV FAILURE

21 Han et al, JTCVS 2016

22 Tricuspid valve procedures with LVAD 336 patients receiving CF LVAD implant 76 underwent TV procedures (22.6%) 68 repairs and 8 replacement Han et al, JTCVS 2016

23 OVERALL 2 YEAR SURVIVAL IN GROUP A (TVP) vs GROUP B (NO TVP) Han et al, JTCVS 2016

24 6 MONTH SURVIVAL BASED ON TVP and DEGREE OF PREOP TR

25 Han et al, JTCVS YEAR READMISSIONS IN TVP vs NO TVP

26 2 YEAR READMISSIONS DUE TO RHF IN TVP vs NO TVP Han et al, JTCVS 2016

27 Han et al, JTCVS 2016

28 Patient Demographics: HMII vs. HMII+TVP Variable of Interest HMII Alone (n=641) HMII + TVP (n=124) p-value Age (years) 58 ± ± Female (%) 142 (22%) 28 (23%) Ischemic (%) 336 (52%) 58 (47%) Mechanical ventilation (%) 31 (5%) 3 (2%) IABP 188 (29%) 38 (31%) Inotrope Use 546 (85%) 98 (79%) DT(%) 364 (57%) 73 (59%) CVP (mm/hg) 12.3 ± ± PVR 3.22 ± ± PCWP 24.6 ± ± RVSWI 576 ± ± CVP/PCWP 0.52 ± ± INR 1.33 ± ± Creatinine (mg/dl) 1.45 ± ± CI 2.03 ± ± BUN 31.3 ± ± AST 57 ± ± L-M Score 9.72 ± ± John et al, JTCVS

29 Patient Demographics: HMII vs. HMII+TVP Variable of Interest HMII Alone (n=641) HMII + TVP (n=124) p-value Age (years) 58 ± ± Female (%) 142 (22%) 28 (23%) Ischemic (%) 336 (52%) 58 (47%) Mechanical ventilation (%) 31 (5%) 3 (2%) IABP 188 (29%) 38 (31%) Inotrope Use 546 (85%) 98 (79%) DT(%) 364 (57%) 73 (59%) CVP (mm/hg) 12.3 ± ± PVR 3.22 ± ± PCWP 24.6 ± ± RVSWI 576 ± ± CVP/PCWP 0.52 ± ± INR 1.33 ± ± Creatinine (mg/dl) 1.45 ± ± CI 2.03 ± ± BUN 31.3 ± ± AST 57 ± ± L-M Score 9.72 ± ± John et al, JTCVS

30 Survival: LVAD Alone vs. LVAD + TVP Only 100 HMII Alone (N=641) HMII + TVP Only (N=124) ± 2% 77 ± 4% 64 ± 2% Survival (%) ± 5% P= Months John et al, JTCVS

31 Summary TRICUSPID VALVE These patients have all the signs of RV failure preop higher CVP, higher CVP/PCWP ratio, lower right ventricular stroke work index (RVSWI), and higher BUN No difference in survival with a tricuspid valve procedure being performed Higher risk of right heart failure in these patients

32 Tricuspid Regurgitation Consider (and do) tricuspid valve repair High CVP refractory to diuretics, IABP, etc Moderate to severe and Severe TR Evidence of leaflet tethering Tricuspid valve repair Beating heart Do not undersize aggressively (often 32 mm tricuspid ring) Tricuspid valve replacement - if repair not feasible

33 Lessons From The Past Good judgment comes from experience, and experience comes from bad judgment. CW Lillihei

34 What are the indications for Tricuspid Valve Repair? Functional severe TR seen with CVP/PWP >0.5 dilated tricuspid valve annulus > 40 mm Severe TR from mechanical problem such as tethered septal leaflet from AICD/pacemaker leaflet Severe TR with evidence of structural damage Moderate- severe TR should also be considered the same way

35 Unanswered Questions What about mild, mild to moderate and moderate TR? Fixing it frequently will come at a price Bleeding Increased adhesions at time of transplant, difficulty with repeat bicaval cannulation

Right Ventricular Failure: Prediction, Prevention and Treatment

Right Ventricular Failure: Prediction, Prevention and Treatment 3 rd European Training Symposium for Heart Failure Cardiologists and Cardiac Surgeons University Hospital Bern June 24-25, 2016 Disclosures: