Tricuspid regurgitation surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2] Fatimo Biobaku M.B.B.S [3]

Overview

Severe primary/secondary tricuspid regurgitation does not predictably improve after left-sided valve surgery, even with correction of any associated pulmonary hypertension, and should be addressed at the time of the index left-sided valve surgery.

Surgery

Indications for Surgery

Recommendations for intervention in tricuspid valve disease
Primary Tricuspid Regurgitation (Class I, Level of Evidence C):
❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction
Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):
❑Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery
Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):
❑Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery
Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):
❑Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery ❑Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension
Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):
❑Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients

The above table adopted from 2021 ESC Guideline

• Shown below is an algorithm depicting the indications for tricuspid valve surgery adapted from the 2014 AHA/ACC guideline for the management of patients with valvular heart disease.
• If the patient does not meet any of the decision pathways in the algorithm, regular monitoring with medical therapy is recommended and surgery is not indicated.

Determine the stage of the tricuspid regurgitation (TR)

Progressive functional (Stage B)

Asymptomatic severe (Stage C)

Symptomatic severe (Stage D)

Is TR mild or moderate?

What is the underlying cause of TR?

Has the TR been previously operated on?

Yes

No

What is the underlying cause of TR?

Mild

Moderate

Functional

Primary

Functional

Primary

The patient is undergoing left-sided valve surgery

The patient is undergoing left-sided valve surgery

The patient is experiencing progressive right ventricular dysfunction AND/OR systolic dysfunction

The patient has persistent symptoms AND The patient has preserved right ventricular function and the pulmonary hypertension is not severe

The patient is undergoing left-sided valve surgery

The patient is unresponsive to medical therapy

The patient has tricuspid annular dilatation OR Prior evidence of right heart failure

The patient has pulmonary hypertension without tricuspid annular dilatation

Tricuspid valve repair (Class IIa)

Tricuspid valve repair (Class IIb)

Tricuspid valve repair or replacement (Class I)

Tricuspid valve repair or replacement (Class IIb)

Tricuspid valve repair or replacement (Class I)

Tricuspid valve repair or replacement (Class IIa)

ESC and EACTS Guideline Recommendation for Surgical Intervention in Tricuspid Regurgitation (2012)

ESC and EACTS Guidelines for Surgical Management (2012)
Primary TR	Class of recommendation	Level of evidence
Severe TR at the time of left-sided valve surgery	I	C
Severe symptomatic isolated TR without severe right ventricular dysfunction	I	C
Moderate TR at the time of left-sided valve surgery	IIa	C
Asymptomatic or mildly symptomatic isolated severe TR and progressive right ventricular dilatation or deterioration of right ventricular function	IIa	C
Secondary TR	Class of recommendation	Level of evidence
Severe TR at the time of left-sided valve surgery	I	C
Mild or moderate TR with dilated annulus (≥40 mm or >21 mm/m²) at the time of left-sided valve surgery	IIa	C
Severe TR late after left-sided valve surgery with symptoms or progressive right ventricular dilatation or dysfunction, in the absence of left-sided valve dysfunction, severe right or left ventricular dysfunction and severe pulmonary vascular disease	IIa	C
TR=tricuspid regurgitation. ESC=European Society of Cardiology. EACTS=European Association of Cardiothoracic Surgery

Surgical Methods

Annuloplasty

The principal surgical repair for secondary TR is tricuspid annuloplasty. The aim of tricuspid annuloplasty is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:

• Ring annuloplasty: It is regarded as the standard for surgical repair. The size of the tricuspid annulus is permanently fixed by implantation of a rigid or semi rigid prosthesis, undersized ring, and it is associated with a reduced incidence of late, recurrent tricuspid regurgitation.
• Suture annuloplasty: It is technically easy and can be done quickly. Also, compared with the ring annuloplasty, a prosthetic implant is not used with suture annuloplasty and the risk of postoperative conduction disturbances is lower.

The transthoracic echocardiography after tricuspid valve repair showed satisfactory leaflet coaptation (A) and repaired papillary muscle (B). Case courtesy by Han-Young Jin et al

Other methods:

• Adjunctive repair techniques: This may be necessary for augmentation of the effects of the ring annuloplasty in patients with marked leaflet tethering and right ventricular remodeling. The long-term outcomes and durability of these adjunctive techniques are not well established. Types of adjunctive repair techniques are listed in the table below.

Anterior leaflet augmentation using an autologous pericardial patch	''Clover'' technique	Double orifice valve technique
Helps improve leaflet coaptation while maintaining leaflet mobility	Approximates the free edges of the three leaflets, producing a clover-shaped valve It has also been used to treat selected patients with complex primary tricuspid regurgitation	Promising outcomes have been reported Done by passing two sutures from the middle of the anterior portion of the annulus to the septal portion of the annulus, forcing leaflet coaptation

• Tricuspid valve replacement
  • Should be undertaken when valve repair is not technically feasible or predictably durable.
  • Valve repair should be considered as the first option in patients with secondary tricuspid regurgitation and marked right ventricular remodeling and leaflet tethering, and in patients with complex primary tricuspid regurgitation or severe tricuspid stenosis.
  • Bioprosthetic valves are currently favored, however, no differences in survival or adverse events at long-term follow-up have been recorded in patients receiving mechanical or biological valves.
• Transcatheter therapies
  • The safety and feasibility of transcatheter therapies for treating severe tricuspid regurgitation are still being investigated.
  • Three types of transcatheter therapies have recently emerged for treating severe tricuspid regurgitation:
    1. Heterotopic caval transcatheter valve implantation
    2. Transcatheter tricuspid valve annuloplasty
    3. Coaptation device

• Transcatheter tricuspid valve replacement
  • This is an experimental study that has been carried out in animals (ewes), it is yet to be done in humans.

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary

Class I

"1. Tricuspid valve surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery. (Level of Evidence: C)"

Class IIa

"1. Tricuspid valve repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either: Tricuspid annular dilation or Prior evidence of right heart failure. (Level of Evidence: B)"

"2. Tricuspid valve surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D). (Level of Evidence: C)"

Class IIb

"1. Tricuspid valve repair may be considered for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery. (Level of Evidence: C)"

"2. Tricuspid valve surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction. (Level of Evidence: C)"

"3. Reoperation for isolated tricuspid valve repair or replacement may be considered for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction. (Level of Evidence: C)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Tricuspid Valve Replacement (DO NOT EDIT)

Class I

"1. Tricuspid valve repair is beneficial for severe TR in patients with mitral valve disease requiring mitral valve surgery. (Level of Evidence: B)"

Class III

"1. Tricuspid valve replacement or annuloplasty is not indicated in asymptomatic patients with TR whose pulmonary artery systolic pressure is less than 60 mm Hg in the presence of a normal mitral valve. (Level of Evidence: C)"

"2. Tricuspid valve replacement or annuloplasty is not indicated in patients with mild primary TR. (Level of Evidence: C)"

Class IIa

"1. Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic. (Level of Evidence: C)"

"2. Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair. (Level of Evidence: C)"

Class IIb

"1. Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic. (Level of Evidence: C)"

Indications for Intervention Adolescents (DO NOT EDIT)

Class I

"1. Surgery for severe TR is recommended for adolescent and young adult patients with deteriorating exercise capacity (NYHA functional class III or IV). (Level of Evidence: C)"

"2. Surgery for severe TR is recommended for adolescent and young adult patients with progressive cyanosis and arterial saturation less than 80% at rest or with exercise. (Level of Evidence: C)"

"3. Interventional catheterization closure of the atrial communication is recommended for the adolescent or young adult with TR who is hypoxemic at rest and with exercise intolerance due to increasing hypoxemia with exercise, when the tricuspid valve appears difficult to repair surgically. (Level of Evidence: C)"

Class IIa

"1. Surgery for severe TR is reasonable in adolescent and young adult patients with NYHA functional class II symptoms if the valve appears to be repairable. (Level of Evidence: C)"

"2. Surgery for severe TR is reasonable in adolescent and young adult patients with atrial fibrillation. (Level of Evidence: C)"

Class IIb

"1. Surgery for severe TR may be considered in asymptomatic adolescent and young adult patients with increasing heart size and a cardiothoracic ratio of more than 65%. (Level of Evidence: C)"

"2. Surgery for severe TR may be considered in asymptomatic adolescent and young adult patients with stable heart size and an arterial saturation of less than 85% when the tricuspid valve appears repairable. (Level of Evidence: C)"

"3. In adolescent and young adult patients with TR who are mildly cyanotic at rest but who become very hypoxemic with exercise, closure of the atrial communication by interventional catheterization may be considered when the valve does not appear amenable to repair. (Level of Evidence: C)"

"4. If surgery for Ebstein’s anomaly is planned in adolescents and young adult patients (tricuspid valve repair or replacement), a preoperative electrophysiological study may be considered to identify accessory pathways. If present, these may be considered for mapping and ablation either preoperatively or at the time of surgery. (Level of Evidence: C)"

Tricuspid Valve Surgery (DO NOT EDIT)

Class I

"1. Severe TR in the setting of surgery for multivalvular disease should be corrected. (Level of Evidence: C)"

Class IIa

"1. Tricuspid annuloplasty is reasonable for mild TR in patients undergoing MV surgery when there is pulmonary hypertension or tricuspid annular dilatation. (Level of Evidence: C)"

Intraoperative Assessment (DO NOT EDIT)

Class I

"1. Intraoperative transesophageal echocardiography is recommended for valve repair surgery. (Level of Evidence: B)"

"2. Intraoperative transesophageal echocardiography is recommended for valve replacement surgery with a stentless xenograft, homograft, or autograft valve.(Level of Evidence: B)"

Class IIa

"1. Intraoperative transesophageal echocardiography is reasonable for all patients undergoing cardiac valve surgery. (Level of Evidence: C)"

Sources

• 2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease