Percutaneous technologies to correct TR : Myth or Reality? Steven F. Bolling, M.D. Professor of Cardiac Surgery University of Michigan
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1 Percutaneous technologies to correct TR : Myth or Reality? Steven F. Bolling, M.D. Professor of Cardiac Surgery University of Michigan
2 Disclosures Ownership Interest: Millipede and Pipeline
3 TR is BAD Decreased CO Fatigue, decreased exercise tolerance Right-sided Heart Failure Ascites, edema, decreased appetite, fullness FTR - feel terrible Valve repair for functional tricuspid valve regurgitation: anatomical and surgical considerations Rogers JH, Bolling SF Semin Thorac Cardiovasc Surg ;22(1):84-9
4 FTR increases Mortality Severe and MODERATE TR increase mortality independent of PASP, LVEF, IVC size, RV size/ function, 5223 pts Nath. JACC 2004;43:405.
5 Severe and MODERATE TR decreases survival Having TR is BAD! Topilsky. JACC 2014.
6 TR after MitraClip for FMR TR Severity Death/Rehosp Ohno et al. EHJ 2014;15:1246. More TR at baseline - worse outcome Moderate or Severe TR is BAD even percutaneously!
7 FTR : Reality Mod /severe TR - BAD
8 Pathophysiology of Functional / Secondary TR What size? NORMAL TRICUSPID ANNULAR DIMENSION cm! Sugimoto, T. J Thorac Cardiovasc Surg 1999;117:463-71
9 Late TR after Functional MR Surgery Matsunaga, Duran. Circulation More TR with TV annulus size
10 FTR: Reality Mod /severe TR - Bad Dilated annulus - Bad
11 Tricuspid Valve Repair- Does it matter? matter 311 Patients MV Repair Preop TR % no/trace/mild 7 % moderate NONE Severe! Dreyfus Annals of Thoracic Surgery 2005
12 TR Does Not Just Go Away After MVr 311 undergoing MVr, mostly degenerative, all with dilated TV annulus TR Worsening by > 2 Grades % MVR only P< % MVR+TVR Dreyfus. Ann Thorac Surg 2005;79:127.
13 Undersized TV repair for FTR Actually Re-NORMAL size!
14 Undersized TV repair for FTR Preoperative None Mild Moderate Mod-to- Severe Severe Predischarge TR Grade None Mild Moderate Mod-to- Severe Severe Follow-up (mean = 1 yr) None Mild Moderate Mod-to- Severe Severe
15 Far less TR, better RV NO mortality or PPM
16 Outcomes of Guideline directed repair of FTR performed during MV surgery Ward, Romano, Bolling : JTCVS pts TVr, mod or < mod TR, 26/28/30 ring No mortality, No TS, RV improved 1% progression to severe TR, 2.6 % de novo PPM rate
17 FTR : Reality Mod/severe TR - BAD TR ring - GOOD
18 Do many patients have TR? STS Database: 58,000 Patients Isolated MR Moderate TR: 12.4 % Severe TR: 7.1 % Moderate or Severe 19.5% Mayo: 115/699 Matsuyama: 46/174 16% Mod/Sev TR 26% Mod + TR Gammie JS Annals of Thoracic Surgery 2009 Yilmaz J Thorac Cardiovasc Surg 2011;142:608 Matsuyama Ann Thorac Surg 2003;75:1826
19 Annular Dilation / Shape Change of FTR : %- all cases of MR!! Normal Tricuspid Annulus Fukuda. Circulation. 2006;114:I-492. Tricuspid Annulus with Functional TR
20 TR is ignored! STS Database 60,000 MR + TR MR - 4,000,000 TR - 1,600, ,000 Annual New MR Annual MR Surgeries Annual TR Surgeries 7,000 TVr
21 Why Not Fix TR at Surgery? I HATE PACEMAKERS! 136 pts, mostly TV repair 8 yr follow up, PPM in 21%,
22 Tricuspid Repair Rate when fixing MR Based on Preop TR Grade 100 Percent of Patients Having Tricuspid Repair None Mild Moderate Severe Preoperative TR Grade Source: STS Database, N = V
23 FTR: Reality Mod/severe TR - Bad TR ring - Good TVR - Sad
24 Percutaneous Implications for TR
25 FTR: Percutaneous Not Rings
26 Tricuspid Regurgitation 4-TECH
27 Tricuspid Regurgitation Mitralign Trialign
28 FTR: Perc McKay? FAILED
29 2 Pair 4 pledgets 2 Locks Target: Full Posterior Annulus 29
30 Pre Procedure Post 1 st Pair Post 2 nd Pair Perc DeVega?
31 12/14 patients received one pair of implants Average annular reduction 35% Average EROA reduction 58% Adverse event 1 access complication Annular Area cm2 EROA cm cm2! cm2! Pre Procedure Post Procedure Pre Procedure Post Procedure 31
32 Tricuspid Percutaneous - Myth TR goal is different.. TR grades 1-4 and 5+ massive 6+ torrential
33 FTR: Percutaneous other things Remain calm! Carry on!
34 FTR Surgery : Percutaneous Implications TV Perc Rings!
35 Tricuspid Regurgitation Cardioband
36 Pre-op Echo : 4+ MR, 3-4+ TR Millipede 36
37 Post MVR / TVR Millipede FLUORO 37
38 24 month Post MVR / TVR Millipede TTE 38
39 24 month Post MVR / TVR Millipede TTE 39
40 Tricuspid Regurgitation - Reality TR is BAD The biology of TR will not change with the method of therapy A new grading method will not fool nature
41 TR severity - reality Sustained, meaningful reduction of TR
42 TR Percutaneous : Myth and reality Less impact Earlier intervention Best TR is zero Good enough? 1-2+TR Reality : Huge market - $$ Patients want it it will happen
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