Hani K. Najm MD, Msc, FRCSC, FRCS (Glasgow), FACC, FESC President of Saudi Heart Association King Abdulaziz Cardiac Centre Riyadh, Saudi Arabia.

Hani K. Najm MD, Msc, FRCSC, FRCS (Glasgow), FACC, FESC President of Saudi Heart Association King Abdulaziz Cardiac Centre Riyadh, Saudi Arabia.

Decision process for Management of any valve Timing Feasibility Risk Results Durability Survival benefit Functional class benefit

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

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.

Survival with TR

Clinical and echocardiographic impact of functional tricuspid regurgitation repair at the time of mitral valve replacement. 1990 to 2005. 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 database. Tricuspid surgery was an independent predictor of early mortality (p= 0.015). (J Heart Valve Dis 2001;10:572 7).

Predictors of the long-term outcome after combined aortic and mitral valve surgery Study period: 1975 to 1989. 170 patients undergoing combined aortic and mitral TV valve pathology surgery. affects survival Mean age: 50.5 years. Follow up (mean): 10.6 years. Early mortality: 4%. Late mortality: 61% (at 10 years). 33% (at 20 years). Tricuspid surgery was an independent predictor of poor late survival rate (p = 0.007).. (Circulation1999;100:II48 53).

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 Carcinoid disease Traumatic Iatrogenic Secondary (Functional) ( 80% ): Left heart valvular dysfunction Any cause of pulmonary hypertension Primary RV dysfunction Volume overload due to intracardiac shunts (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).

Functional Tricuspid Regurgitation The most frequent cause of tricuspid insufficiency. Often secondary to left-sided valve diseases. If left uncorrected at left-sided valve surgery, leads to progressive right-heart dysfunction, and poor long-term prognosis with need for re-operation.

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 (Kay) Edge-to-edge or clover technique. Suture bi-cuspidization 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

KACC experience Preoperative data 2000-2010 133 patients Mean age... 48.3 ± 15.3 Male... 36 (27%) NYHA... I II 60 (45%) NYHA III... 54 (34%) NYHA IV... 28 (21%)

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

Preoperative data III Previous TV surgery 4 patients: S/p TVR 2 patients: - Bioprosthesis... 2 pt TV repair/construction... 2 pts

Operative data Lone TVR/repair in 2 patients: a 20 y/o female with severe TS and Ebstein syndrome and she had TVR Medtronic Mosaic. 43 y/o male with isolated TV mixed lesion TV repair with PeriGuard ring. 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

1976 and 2002. 463 patients. 478 tricuspid annuloplasty procedures for TR. With associated left-sided valve surgery. 107(23%): De Vega semicircular annuloplasty. 267 (58%): Bex flexible linear reducer. 89 (19%): Carpentier-Edwards prosthetic ring annuloplasty.. Michel Carrier et al. J Heart Valv Dis 2004;13:952-956

Tricuspid Valve Repair: An Old Disease, a Modern Experience José M. Bernal et al. 1987 and 1999. 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%, (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 1978 to 2003. 702 patients undergoing TV repair. Primary TR 26%. Functional TR:74%. 493 De Vega procedure. 209 Ring annuloplasty. Concomitant procedures: Mitral valve surgery (80%), aortic valve surgery(33%), Coronary bypass (14%). Use of an annuloplasty ring 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.)

Midterm follow up data at KACC The mean period of f/up was 17.9+25.6 (6mos-7 years) The latest LVEF% = 55.1±15.14 The latest RVSP = 41.9 ± 12.7 Severe recurrent TR was found in... 7 non standard repair... 2 De Vega... 1 Bicuspidization tech... 1 Cosgrove Edwards ring... 3

Recurrent TR after TV Repair

Re-operations after tricuspid valve repair José M. Bernal et al 1976 to 2002. 74 re-operations following previous TV repair. Mean age of 53.8+12.2 years. 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%+4.9% at 26 years. J Thorac Cardiovasc Surg 2005;130:498-503

Predictors of early and late mortality after TV re-operations. J Thorac Cardiovasc Surg 2005;130:498-503

Tricuspid valve Repair Versus Replacement

1979 to 2003. 250 pts underwent surgery for organic TV disease. 178 (71%) TV repair 72 (29%) TV replacement (54 bioprosthetic, 18 mechanical). Concomitant procedures: mitral (50% of patients), aortic (26%), and coronary bypass (6%) operations. More moderate to severe tricuspid regurgitation in repair patients (38% vs 5%, p < 0.001). However, no difference in New York Heart Association functional class or reoperation rates. Singh et al. (Ann Thorac Surg 2006;82:1735 41

Tricuspid valve surgery: a thirty-year assessment of early and late outcome 1974 to 2003. 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 February 1986 to July 2006, 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 similar for 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. January1973 to September 1996. 87 patients(85% Females) underwent TV replacement. (52 tissue valves, 35 mechanical prostheses). 19 (23%) isolated TVRs 25(29%) double valve, 43 (49%) triple valve replacements. Cumulative follow up was 707patient-years. Mean follow up was 8.1 years (range: 0 to 23.6 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 +/-5.3% at 5 years, 52 +/- 5.9% at 10 years, 35 +/- 6% at 15 years 16 +/- 5.3% at 20 years. Freedom from tricuspid valve re-operation at 5, 10 and 15 years was 93, 83 and 71 respectively. 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 endocarditis and three for prosthetic valve degeneration). (J Heart Valve Dis. 1999 Nov;8(6):644-8)

Conclusions TV regurgitation affects survival Tricuspid repair is preferable Repair is feasible in most cases Ring repair seems to be superior to other techniques If replacement is necessary then a bioprosthesis