Tricuspid regurgitation surgery: Difference between revisions

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==Overview==
==Overview==
[[Pulmonary hypertension]] or [[myocardial]] [[disease]] are two factors that affect the treatment of [[secondary TR]]. The surgical approach is considered for selected [[patients]] with severe [[TR]] (stage C,D) at the time of [[surgery]] for [[left-sided valve lesions]] and to prevent later development of severe [[TR]] in [[patients]] with progressive [[TR ]] (Stage B). 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]]), [[surgical intervention]] is recommended. [[Mortality rate]] is high in [[patients]] undergone interventions for severe isolated [[TR]]. However, outcomes of [[patients]] with severe [[primary TR]] are poor with medical management. Earlier surgery for [[patients]] with severe isolated [[TR]] before the onset of severe [[RV dysfunction]] or [[end-organ damage]] is recommended.
[[Pulmonary hypertension]] or [[myocardial]] [[disease]] are two factors that affect the treatment of [[secondary TR]]. The surgical approach is considered for selected [[patients]] with severe [[TR]] (stage C,D) at the time of [[surgery]] for [[left-sided valve lesions]] and to prevent later development of severe [[TR]] in [[patients]] with progressive [[TR ]] (Stage B). 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]]), [[surgical intervention]] is recommended. [[Mortality rate]] is high in [[patients]] undergone interventions for severe isolated [[TR]] due to [[end-organ damage]] at the time of [[surgery]]. However, outcomes of [[patients]] with severe [[primary TR]] are poor with medical management. Earlier surgery for [[patients]] with severe isolated [[TR]] before the onset of severe [[RV dysfunction]] or [[end-organ damage]] is recommended.


==Surgery==
==Surgery==

Revision as of 05:21, 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

Pulmonary hypertension or myocardial disease are two factors that affect the treatment of secondary TR. The surgical approach is considered for selected patients with severe TR (stage C,D) at the time of surgery for left-sided valve lesions and to prevent later development of severe TR in patients with progressive TR (Stage B). 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), surgical intervention is recommended. Mortality rate is high in patients undergone interventions for severe isolated TR due to end-organ damage at the time of surgery. However, outcomes of patients with severe primary TR are poor with medical management. Earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage is recommended.

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[1]


















  • 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.
leaflet coaptation
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 [6]


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
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.[7]

References

  1. ↑ 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).
  2. ↑ 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.
  3. ↑ 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. ↑ 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).
  5. ↑ 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.
  6. ↑ "A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture".
  7. ↑ 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

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