Tricuspid regurgitation surgery: Difference between revisions
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==Overview== | ==Overview== | ||
Treatment of [[secondary TR]] is targeted at pulmonary hypertension or myocardial disease. Surgical treatment is performed for selected patients with TR at the time of surgery for left-sided valve lesions to treat severe TR (Stages C and D) and to prevent later development of severe TR in patients with progressive TR (Stage B). Surgical intervention should be considered for selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy). Intervention for severe isolated TR had a high reported operative mortality rate (up to 8% to 20%), but most of these interventions were performed after end-organ damage.21 However, outcomes of patients with severe primary TR are poor with medical management. There is renewed interest in earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage.2,11,12,18,19,22 This interest is attributable to 1) an increasing number of patients presenting with right-sided HF from isolated TR,23–25 2) more advanced surgical techniques, and 3) better selection processes, resulting in a lower operative risk with documented improvement in symptoms | Treatment of [[secondary TR]] is targeted at [[pulmonary hypertension]] or[[ myocardial disease]]. Surgical treatment is performed for selected patients with TR at the time of surgery for left-sided valve lesions to treat severe TR (Stages C and D) and to prevent later development of severe TR in patients with progressive TR (Stage B). Surgical intervention should be considered for selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy). Intervention for severe isolated TR had a high reported operative mortality rate (up to 8% to 20%), but most of these interventions were performed after end-organ damage.21 However, outcomes of patients with severe primary TR are poor with medical management. There is renewed interest in earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage.2,11,12,18,19,22 This interest is attributable to 1) an increasing number of patients presenting with right-sided HF from isolated TR,23–25 2) more advanced surgical techniques, and 3) better selection processes, resulting in a lower operative risk with documented improvement in symptoms | ||
==Surgery== | ==Surgery== | ||
Revision as of 05:06, 4 June 2022
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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
Treatment of secondary TR is targeted at pulmonary hypertension ormyocardial disease. Surgical treatment is performed for selected patients with TR at the time of surgery for left-sided valve lesions to treat severe TR (Stages C and D) and to prevent later development of severe TR in patients with progressive TR (Stage B). Surgical intervention should be considered for selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy). Intervention for severe isolated TR had a high reported operative mortality rate (up to 8% to 20%), but most of these interventions were performed after end-organ damage.21 However, outcomes of patients with severe primary TR are poor with medical management. There is renewed interest in earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage.2,11,12,18,19,22 This interest is attributable to 1) an increasing number of patients presenting with right-sided HF from isolated TR,23–25 2) more advanced surgical techniques, and 3) better selection processes, resulting in a lower operative risk with documented improvement in symptoms
Surgery
Indications for Surgery
| Recommendations for intervention in tricuspid valve disease | |
| Primary Tricuspid Regurgitation (Class I, Level of Evidence C): | |
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❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery | |
| Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C): | |
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❑Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery | |
| Secondary Tricuspid Regurgitation (Class I, Level of Evidence B): | |
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❑Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery | |
| Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B): | |
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❑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 | |
| Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C): | |
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❑Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients |
| The above table adopted from 2021 ESC Guideline[1] |
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- 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.[2][3]
| 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) | ||||||||||||||||||||||||||||||||||||||||||||||||||
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:[4][5]
- 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.
Other methods:[4]
- 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 |
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| Helps improve leaflet coaptation while maintaining leaflet mobility |
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- 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:
- Heterotopic caval transcatheter valve implantation
- Transcatheter tricuspid valve annuloplasty
- 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.[7]
References
- ↑ Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check
|pmid=value (help). - ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
- ↑ Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553.
- ↑ 4.0 4.1 Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check
|pmid=value (help). - ↑ Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O (2012). "The growing clinical importance of secondary tricuspid regurgitation". J Am Coll Cardiol. 59 (8): 703–10. doi:10.1016/j.jacc.2011.09.069. PMID 22340261.
- ↑ "A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture".
- ↑ Boudjemline Y, Agnoletti G, Bonnet D, Behr L, Borenstein N, Sidi D et al. (2005) Steps toward the percutaneous replacement of atrioventricular valves an experimental study. J Am Coll Cardiol 46 (2):360-5. DOI:10.1016/j.jacc.2005.01.063 PMID: 16022968 PMID 16022968