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

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

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)

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.