Imaging to select patients for Transcatheter TV
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1 Imaging to select patients for Transcatheter TV Jeroen J Bax Dept of Cardiology Leiden Univ Medical Center The Netherlands San Diego, february 2018 Research grants: Medtronic, Biotronik, Boston Scientific, Edwards Lifescience Tricuspid Regurgitation TV remains as the forgotten valve Referral for isolated surgical TV repair unfrequent Moderate to severe TR affects1.6 million US patients Only 8,000 patients/year undergo TV surgery Prognostic implications 1
2 Tricuspid valve Anterior Septal Posterior Tricuspid Anatomy Taramasso et al. EHJ 2015 Close are: AV node, CS, RCA 2
3 What is important? Cause of TR: Organic Functional TR grade: quantification Tricuspid annulus dimensions / geometry RV dimensions and function Tricuspid Regurgitation 90% is functional TR TR due to RV dilatation in the presence of LV dysfunction 3 stages of disease progression 3
4 Development of TR RV dilation TA dilation More RV dilation Lack of TV coapt TV tethering TR; pulm HT Taramasso et al. EHJ 2015 Functional Tricuspid Regurgitation: Prognostic Implications 5,223 patients 98% functional TR 1-year survival: Mild TR: 90.3% Moderate TR: 78.9% Severe TR: 63.9% Nath et al. J Am Coll Cardiol
5 Tricuspid Regurgitation: Prognostic Implications TR after left-sided VHD surgery Log-rank test p < patients 69±12 years old 65% prior AVR 19% prior MV surgery Kammerlander et al. J Am Coll Cardiol 2014 Tricuspid Regurgitation: Prognostic Implications 239 patients 60±14 years old 20% pacemakers 80% ICD CRT excluded Hoke et al. Heart
6 What is important? Cause of TR: Organic Functional TR grade: quantification Tricuspid annulus dimensions / geometry RV dimensions and function TR grade: quantification VC width 0.8cm Dense CW Systolic reversal hepatic flow Lancellotti et al. Eur Heart Cardiovasc Imag
7 What is important? Cause of TR: Organic Functional TR grade: quantification Tricuspid annulus dimensions / geometry RV dimensions and function Tricuspid annular dimensions >70 mm surgical measurement >40 mm 4ch-view TTE Dreyfus et al. Ann Thorac Surg
8 Tricuspid annular dimensions N = 138 patients Dreyfus et al. Circ Cardiovasc Imag 2015 Tricuspid annular dimensions Van Rosendael et al. EHJ Imaging
9 TR: TV geometry Coaptation height >4 mm significant leaflet tethering >8 mm increased risk of TVA failure Dreyfus et al. Eur J Cardio-thoracic Surg 2008 What is important? Cause of TR: Organic Functional TR grade: quantification Tricuspid annulus dimensions / geometry RV dimensions and function 9
10 RV dimensions and function Van Rosendael et al. EHJ Imaging 2016 New therapies: Transcatheter Tricuspid Valve Procedures Heterotopic implantation of caval valves Direct annuloplasty Filling the coaptation gap TV replacement F. Maisano EuroPCR
11 New therapies: Transcatheter Tricuspid Valve Procedures Heterotopic implantation of caval valves Transcath prosthesis in VCI and/or VCS Advanced RV dysfunction only 1 prosthesis to avoid RV failure F. Maisano EuroPCR 2015 Assessment of IVC: max min diameter perimeter and area Van Rosendael et al. Eurointervention
12 New therapies: Transcatheter Tricuspid Valve Procedures Forma concept Spacer positioned in TV orifice Distally anchored RV apex Filling the coaptation gap Improve leaflet coaptation F. Maisano EuroPCR 2015 Assessment of distance TV annulus to RV apex Long-axis 4- chamber view Filling the coaptation gap Measure distance from TV annulus to RV apex Van Rosendael et al. Eurointervention
13 New therapies: Transcatheter Tricuspid Valve Procedures TriCinch device Corkscrew implanted in target zone System is tensioned to reshape the TV annulus (TV annuloplasty) F. Maisano EuroPCR 2015 Stent displayed in IVC to keep tension TriCinch concept 13
14 Course of RCA vs TV annulus Van Rosendael et al. Eurointervention 2015 Assessment of distance RCA to TV annulus Van Rosendael et al. Eurointervention
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