Clinical Outcome of Tricuspid Regurgitation. David Messika-Zeitoun

Transcription

1 Clinical Outcome of Tricuspid Regurgitation David Messika-Zeitoun

2 I have financial relationships to disclose Consultant for: Edwards, Symetis and Valtech

3 Tricuspid Regurgitation is a Common Finding

4 Tricuspid Regurgitation (TR) in Normal Subjects Mitral regurgitation 65 Tricuspid regurgitation 12 Total 50 years >50 years 7 17 Aortic regurgitation Levine Chest 1993; 103: 226

5 % Prevalence of TR in the General Population (The Framingham Heart Study) participants, 1696 men and 1893 women Mitral regurgitation Tricuspid regurgitation None or trace Mild Moderate Sing AJC 1999; 83:

6 % Prevalence increase with age Mild TR Moderate TR Sing AJC 1999; 83: < AGE (years)

7 % Prevalence of TR in patients with LV dysfunction 1421 patients with LVEF < 35% Mitral regurgitation Tricuspid regurgitation 10 0 None or mild Moderate Severe Koelling Am Heart Journal 2002; 144: 524-9

8 How to Assess the Severity of Tricuspid Regurgitation?

9 Jet Area

10 Jet area (cm 2 ) Jet Area I II Angiographic grade III Grossmann EHJ 1998; 19:

11 Hepatic Flow Reversal Systolic reversal Sensitivity: 80% Specificity: excellent Reversal Normal S S

12 Conservation of mass Proximal Isovelocity Surface Area Flow 2 = Flow 1

13 PISA - Difference TR vs. MR MR TR

14 Effective Regurgitant Orifice (ERO) and Regurgitant Volume (Rvol) R flow = ERO Vmax TVI Vmax = x ERO = 80 / 300 = 0.27 cm 2 Rvol ERO TVI Rvol = 0.27 x 89 = 24 ml

15 Contrasting Effect of Similar ERO in MR and TR Regurgitant Volume Effective Regurgitant Orifice Volume overload Lesion severity

16 Comparison MR-TR 300 MR TR Regurgitant volume (ml) Effective regurgitant orifice (mm 2 ) Tribouilloy JASE 2002; 15:

17 Thresholds for Severe Regurgitation Organic MR Functional MR AR TR Régurgitant Volume, ml Effective regurgitant orifice, cm²

18 Vena Contracta - Principle Flow convergence Vena contracta Jet

19 Vena Contracta Diagnostic Value for Severe TR Tribouilloy JACC 2000; 36:

20 Is Tricuspid Regurgitation Bad?

21 Event Free Survival, % Functional TR and Survival in Patients with CHF 117 patients with severe CHF (pre-transplant evaluation) TR P = TR Hung AJC 1998; 82: Weeks

22 SURVIVAL TR Grade and Survival in Patients with LV dysfunction patients with LVEF < 35% TR (and MR) independent predictor of mortality P = None or mild TR Moderate TR Severe TR DAYS Koelling Am Heart Journal 2002; 144: 524-9

23 SURVIVAL TR Grade and Survival patients, echocardiography at Veterans Centers No TR Mild TR Moderate TR Severe TR P < DAYS After adjustment for age, LVEF, IVC size, RV size and RV function, S-PAP Nath JACC 2004; 43: 405-9

24 Is TR Cause or Marker of impaired Prognosis?

25 Clinical Situations 1. Severe isolated TR 2. Left-sided surgery 1. Severe TR 2. Moderate TR 3. No or mild TR

26 Clinical Situations 1. Severe isolated TR 2. Left sided surgery 1. Severe TR 2. Moderate TR 3. No or mild TR

27 Tricuspid Flail A Model of Isolated Severe Organic TR

28 Tricuspid Flail

29 Population 60 patients Mean age: 51 ± 26 years Men: 62% Right ventricular enlargement: 35 (58%) Asymptomatic: 26 (43%) Atrial fibrillation History: 40% At presentation: 25%

30 Etiologies of flail leaflets MITRAL FLAILS TRICUSPID FLAILS Traumatic non iatrogenic 2% Idiopathic 1% Degenerative 77% Other 3% Endocarditis 8% Idiopathic 15% Traumatic iatrogenic 32% Endocarditis 20% Degenerative 12% Traumatic non iatrogenic 30%

31 Messika-Zeitoun JTCS 2004; 128: Impact of TR on Outcome

32 Event (%) Effect on outcome of rightsided chambers enlargement P < 0.01 HR: 1.76, p=0.02 Severe enlargement of right cavities 89± ± Years after diagnosis Non-severe enlargement of right cavities

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35 Operative mortality 10% Predictive factors of post-op outcome -Age / Charlson / Ambler -NYHA class -Renal function -Right ventricular function

36 Predictive factors of post-op outcome -Hemoglobin -Renal function -Liver function -Right ventricle size -Residual TR

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38 Severe TR Is associated with an increased long-term morbidity and mortality Consider early surgery before the occurrence Chronic atrial fibrillation Severe right ventricular enlargement and dysfunction Intractable congestive heart failure with renal and liver dysfunction

39 Clinical Situations 1. Severe isolated TR 2. Left sided surgery 1. Severe TR 2. Moderate TR 3. No or mild TR

40 Does the treatment of left-sided disease cure the TR?

41 TR Resolution post Mitral Valve Commissurotomy % Trace or Mild TR Moderate TR Severe TR Resolution in 32% Independent predictors: TR jet area before PBMV Decrement of peak mitral gradient after PBMV (=success of the procedure) 0 Pre-PBMV Post-PBMV SONG AHJ 2003; 145:371-6

42 The treatment of leftsided disease only partially cure TR

43 Clinical Situations 1. Severe isolated TR 2. Left sided surgery 1. Severe TR 2. Moderate TR 3. No or mild TR

44 TR after Mitral Valve Surgery 174 patients with isolated mitral valve surgery and TR grade 2/ N=17 N=11 N=28 1/3 third of non corrected moderate TR developed severe TR % Trace or Mild TR 20 Moderate TR Severe TR 10 0 Pre-op Fup MATSUYAMA Ann Thor Surg 2003

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46 Clinical Situations 1. Severe isolated TR 2. Left sided surgery 1. Severe TR 2. Moderate TR 3. No or mild TR

47 Could I feel safe in the absence of TR?

48 TR grade Development of TR late after Left-sided Valve Surgery 163 patients with isolated mitral valve repair (mainly degenerative MR) and TR grade < 2/4 Fup at 5 years P< ± patients with grade 3 or 4/ ±0.5 DREYFUS Ann Thor Surg

49 Determinants of late TR -Age -Female gender -AF -Post S-PAP -Rheumatic etiology 7.3%

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52 Late occurrence of TR is frequent even in no or mild TR and portends an adverse prognosis

53 How to better assess the risk of occurrence of severe TR?

54 Pathogenesis of TR Annular enlargement AF Tethering Right-sided chambers remodeling LOADING CONDITIONS

55 A Strategy Based on Annulus Diameter Measurements Maximal diastolic size of the tricuspid annulus between the anteroseptal and anteroposterior commissure DREYFUS Ann Thor Surg 2005

56 NYHA class A Strategy Based on Annulus Diameter Measurement < 70 mm 70 mm ±0.8 P< Isolated Mitral valve repair N=163 Mitral valve repair + 1 tricuspid annuloplasty 0.5 N=148 0 MVR 1.1±0.3 MVR + TA

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59 Tricuspid annulus diameter seems a good parameter to guide the indication for tricuspid surgery but limited data and thresholds need to be further defined

60 Conclusion TR is a common finding TR by itself is an important prognostic factor and surgery should be considered early in severe TR before the occurrence of severe complications TR does not always regress after correction of left-sided disease and often progresses over time and negatively impacts the outcome

61 Moderate / Severe TR No / mild TR Tricuspid surgery in case of large annulus - Mitral valve surgery - Rheumatic etiology - AF - High S-PAP - Significant right-sided chambers enlargement

62 Thank you

63 Valvular Heart Disease ESC Working Group