Hani K. Najm MD, Msc, FRCSC FACC, FESC President Saudi Society for Cardiac Surgeons Associate Professor of Cardiothoracic Surgery King Abdulaziz Cardiac Centre Riyadh, Saudi Arabia
Decision process for intervention of any valve Timing Feasibility Risk Results Durability Survival benefit Functional class benefit
Problems with evaluation of TV surgery Usually it is not the primary indication for intervention Symptoms of left sided valves appear earlier Symptoms are tolerated for longer time than left sided valves There are no clear cut off limits for intervention Repair techniques are not standardized like the MV Functional class and survival could be determined by the left sided lesions.
Does TR affects Survival
Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement. 624 patients undergoing MVR. Preoperative TR exceeded 2+ in 231. Only 125 received tricuspid repair and MVR. 106 received MVR alone. Mean follow-up: 6.8 +/- 4.8 years. RESULTS: TR exceeding 2+ at operation was associated with a 53% increase in late death (p =0.003). Tricuspid repair: prevented echo progression of TR (p <0.01). improved congestive heart failure ( p < 0.01). But overall survival did not improve (p = 0.3). (Ann Thorac Surg. 2009 Oct;88(4):1209-15).
Risk factors for early mortality after valve surgery in Europe in the 1990s: lessons from the EuroSCORE pilot program. 5,672 patients undergoing valve surgery from 128 european centre. Analysed by EuroSCORE TR affects database. survival Tricuspid surgery was an independent predictor of early mortality (p= 0.015). (J Heart Valve Dis 2001;10:572 7).
Options for surgery Repair: Advantages Preservation of patients own tissue Less incidence of thromboimbolism, endocarditis, Preservation of LV function Superior hemodynamics Disadvantages Needs expertise May not be durable
Options for surgery Replacement Advantages Easy surgery Readily available sizes of prosthetic valves Disadvantages Anticoagulation Degeneration Endocarditis Thromboimbolism
Etiology of Tricuspid Regurgitation Primary (Organic) ( 20% ): Rheumatic Myxomatous Ebstein anomaly Endomyocardial fibrosis Endocarditis Carcinoiddisease Traumatic Iatrogenic Secondary (Functional) ( 80% ): Left heart valvulardysfunction Any cause of pulmonary hypertension Primary RV dysfunction Volume overload due to intracardiacshunts (Circulation. 2009;119:2718-2725.)
Rheumatic involvement of Tricuspid Valve Rheumatic Heart disease involving tricuspid valve is much less common than mitral & aortic valves. Out of 2,497 rheumatic heart disease patients (mean age 25.5 years) RHD of tricuspid valve was detected in 193 patients (7.7%) by echocardiography. (Sultan et al. J Heart Valve Dis. 2010 May;19(3):374-82).
Tricuspid Annular Morphology Tricuspid annulus is saddle shaped, with the highest points located in an antero-posterior orientation and the lowest points in a mediolateral orientation. Fukuda et al. Circulation. 2006;114(suppl):I-492 I-498.
Annular changes in severe TR 1)Annulus becomes dilated (17.24+4.75 versus 9.83+2.18 sq.cm, P< 0.0001). 2)More planar with decreased high-low distance (4.14+1.05 mm versus 7.23+1.05 mm) 3)More circular with decreased ratio of medio-lateral/anteroposterior diameter (1.11+.09 versus1.32+.09, P< 0.0001). Thanh-Thao Ton-Nu et al. (Circulation. 2006;114:143-149)
Tricuspid Valve Repair Techniques stitch annuloplasty semicircular (classical De Vega repair) lateral annuloplasty (bi-cuspidization,kay) Edge-to-edge or clover technique. Use of flexible and rigid prosthetic rings,3d rings or flexible prosthetic bands.
C-E Rigid Ring
MC3 Ring Remodeling And Reduction annuloplasty
Pericardial strip annuloplasty Feasible in almost All cases
Best evidence (390 papers) TV repair should be performed independent of grade in Annular dimension over 21mm/m 2 Measurement by echo of 3.5 cm Intraop >70 mm
Tricuspid Valve Repair: An Old Disease, a Modern Experience 232 consecutive patients. Etiology: Rheumatic (186) Degenerative (46). Functional(128). Organic(104). Concommitant surgery: 227 Mitral valve. 90 Aortic valve. De Vega s: 93(40.1%). Segmental annuloplasty 139(59.9%). Follow up (mean): 6.8 years (range, 2 to 12 years). Results: Hospital mortality: 8.1%. Late mortality: 23.3%, José M. Bernal et al.(ann Thorac Surg 2004;78:2069 75)
Actuarial survival curve TV repair with left-sided valve surgery (Ann Thorac Surg 2004;78:2069 75)
TV repair with left-sided valve surgery Freedom from re-operation Durability??? Freedom from valve-related complications (Ann Thorac Surg 2004;78:2069 75)
Ring annuloplasty versus Suture annuloplasty
Tricuspid Valve Repair With an Annuloplasty Ring Results in Improved Long-Term Outcomes 702 patients undergoing TV repair. 493 De Vega procedure. 209 Ring annuloplasty. Use of an annuloplastyring was an independent predictor of: Long-term survival (HR,0.7; 95%;CI, 0.5 to 1.0; P=0.03). Event-free survival (HR, 0.8; 95%CI, 0.6 to 1.0; P=0.04). Gilbert H. L. Tang et al.(circulation. 2006;114[suppl I]:I-577 I-581.)
Recurrent TR after TV Repair
José M. Bernal et al J Thorac Cardiovasc Surg 2005;130:498-503 Re-operations after tricuspid valve repair 74 re-operations following previous TV repair. 92% required mitral &/or aortic valve surgery. Reoperations: TV replacement: 43 patients (58.1%). Re-do TV repair : 31 patients (41.9%). Hospital mortality:35.1% (n 26). Late mortality: 40.5% (n 30). Actuarial survival: 11.8% at 26 years.
Tricuspid valve Repair Versus Replacement
Tricuspid valve surgery: a thirty-year assessment of early and late outcome n=416 366(88%): concomitant mitral (n = 340) or aortic (n = 100) valve surgery. Tricuspid valve repaired: 310 (74.5%) replaced: 106 (25.5%). Biological prosthesis used in 68 patients Overall 30-day mortality repair (13.9%) replacement (33%) ( p < 0.001)]. Thomas Guenther et al. (Eur J Cardiothorac Surg 2008;34:402-409)
Eur J Cardiothorac Surg 2008;34:402-409
Eur J Cardiothorac Surg 2008;34:402-409
Outcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis 315 patients underwent tricuspid valve surgery. 93 replacements (72 biologic, 21 mechanical). 222 repairs. Matched cohort of patients was selected using propensity score analysis (68 patients in each group). Results: Operative mortality was similarfor tricuspid valve replacement (13%+4%) and repair (18%+5%); (p = 0.64). ICU length of stay was similar between cohorts (replacement, 4 days; repair, 3 days; p = 0.45). Replacements had a significantly longer hospital lengths of stay (9 days versus 6 days; p = 0.01). 1 year, 5 year and 10 year survival was similar (p = 0.66). Moraca RJ et al. (Ann Thorac Surg 2009;87:83 9)
Survival TV repair versus replacement (Propensity analysis) Moraca RJ et al. (Ann Thorac Surg 2009;87:83 9)
Bioporsthtic is better for TV Avoid anticoagulation Bioprosthetic degeneration is less in low pressure system Maintain the ability to intervene through the TV
Tricuspid valve replacement: bioprostheses are preferable. 87 patients underwent TV replacement. (52 tissue valves, 35 mechanical prostheses). 23% isolated TVRs 29% double valve, 49% triple valve replacements. Mean follow up was 8.1 years (J Heart Valve Dis. 1999 Nov;8(6):644-8)
Tricuspid valve replacement: bioprostheses are preferable Early mortality rate: 10.3%. Risk factors: prolonged cardiopulmonary bypass time (p <0.03) advanced NYHA functional class (p <0.007) Survival rate was 68% at 5 years, 16 % at 20 years. Re-operation: 6 (17%) mechanical valves (five for prosthetic valve thrombosis and one for mechanical failure secondary to pannus ingrowth), 5 (9.6%) tissue valves (two for prosthetic valve endocarditisand three for prosthetic valve degeneration). (J Heart Valve Dis. 1999 Nov;8(6):644-8)
KACC experience Preoperative data 2000-2010 133 patients Mean age... 48.3 ± 15.3 Male... 36 (27%) NYHA II... 60 (45%) NYHA III - IV... 72 (55%)
TV disease Aetiology 90 80 70 60 50 40 30 20 10 0 Rheumatic 23 pts IE native valve 14 pts IE prosthesis 4 pts Calcific 4 ts Congenital 1 pt Functional 84 pts
Preoperative Data Organic TV disease Moderate and above TS was found in 7 patients: - 5 associated with moderate to severe MR - 1 associated with severe AI - 1 Ebstein syndrome Functional TR was encountered in 126 patients: - Moderate 2+... 36 pts - Severe 3+... 61 pts - Severe 4+... 29 pts
Associated Valve Disease 140 120 100 80 60 40 20 AS MS 32 pts 15 pts MR AI 76 pts 40 pts CAD 0 Aortic 54 pts Mitral 108 pts CAD 20 pts
Operative data TV repair in 124 patients. TV replacement in 9 patients: Medtronic Mosaic... 7 CE Perimount Magna... 2
Concomitant Aortic surgery... 33 Tissue : CE Perimount... 1 Medtronic Mosaic Magna... 3 Mechanical: ATS... 3 Carbomedics Standard... 13 Carbomedics Tophat... 5 St Jude standard... 2 St Jude Regent... 6
Conc. Mitral valve surgery 110 pts: MVR Tissue valve... 21 pts: Medtronic Mosaic... 14 CE Perimount Magna... 7 MVR mechanical valve 62: ATS... 7 Carbomedics... 55 Mitral valve repair... 23 pts: CE Physio ring... 11 Cosgrove Edwards ring... 10 Stitch or band repair:... 2
Concomitant CABG TVR/repair + CABG... 20 pts: CABG + AVR... 2 CABG + MVR/repair... 15 CABG + AVR+ MVR/repair... 3
Operative data
In-hospital Mortality Euroscore...9± 6.1 Over all mortality 6(5%) Cardiac Risk is acceptable 2 patients Multi organ failure Neurological Others 2 patients 1 patient 1 patient
Midterm follow up data at KACC The mean period of f/up was 17.9+25.6 (6mos-7 years) Severe recurrent TR was found in... 7 non standard repair... 2 De Vega... 1 Bicuspidization tech... 1 Cosgrove Edwards ring... 3
Conclusions TV regurgitation affects survival Tricuspid repair is preferable Repair is feasible in most cases Ring repair or Bicuspidization may be similar If replacement is necessary then a bioprosthesis