When to perform
Tricuspid valve
Surgery?
Julien Dreyfus MD and
David Messika-Zeitoun MD, PhD
Bichat Hospital, Paris, Franc...
When to perform Tricuspid valve Surgery?
• A case by the ESC Working Group on Valvular Heart Disease
When to perform Tricuspid valve Surgery?
• 55 year old female

• No cardiovascular risk factors
• Rheumatic mitral stenosi...
The Mitral Valve
Watch
video

Watch
video

Watch video

Watch video

Watch video

Mitral valve area =
1.3 cm²

Mean Gradie...
The Tricuspid Valve

Watch
video

Watch
video
What is you management strategy?

1.Repeat percutaneous mitral commissurotomy

2.Isolated mitral valve replacement

3.Comb...
What is you management strategy?

1.Repeat percutaneous mitral commissurotomy

2.Isolated mitral valve replacement

3.Comb...
What is you management ?

1.Repeat percutaneous mitral commissurotomy
One commissure is completely open and MR
grade is > ...
Same patient but
different tricuspid
disease…
Watch video
What is you management strategy?

1.Repeat percutaneous mitral commissurotomy

2.Isolated mitral valve replacement

3.Comb...
What is you management strategy?

1.Repeat percutaneous mitral commissurotomy

2.Isolated mitral valve replacement

3.Comb...
Tricuspid annular
diameter
Limitations of surgical strategy based only on
degree of TR
1. After isolated mitral valve replacement, 30-50% of patients...
Limitations of surgical strategy based only on
degree of TR
1. After isolated mitral valve replacement, 30-50% of patients...
Limits of a surgical strategy only based on TR
degree
1. After isolated mitral valve replacement, 30-50% of patients
devel...
Limits of a surgical strategy only based on TR
degree
1. After isolated mitral valve replacement, 30-50% of patients
devel...
Strategy based on annular diameter
• In 311 patients who underwent mitral valve repair a
tricuspid annuloplasty was perfor...
Strategy based on annular diameter
• In 311 patients who underwent mitral valve repair a
tricuspid annuloplasty was perfor...
Comparison of a strategy based on TR degree
alone OR TR degree and annular diameter
• First cohort:
2002-2004.
Associated ...
Comparison of a strategy based on TR degree
alone and TR degree and annular diameter

• A strategy based on TR degree and
...
Associated tricuspid annuloplasty
during mitral valve repair /
replacement should be
considered in patients with
tricuspid...
Guidelines on the management of valvular
heart disease (version 2012)

Vahanian et al. European Heart Journal 2012; 33(19)...
TAKE HOME MESSAGES

• During left-sided valve surgery,
combined tricuspid valve surgery
(annuloplasty or replacement)
shou...
Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !

Membership is FREE!
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When to perform Tricuspid valve Surgery?

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When to perform Tricuspid valve Surgery?

  1. 1. When to perform Tricuspid valve Surgery? Julien Dreyfus MD and David Messika-Zeitoun MD, PhD Bichat Hospital, Paris, France
  2. 2. When to perform Tricuspid valve Surgery? • A case by the ESC Working Group on Valvular Heart Disease
  3. 3. When to perform Tricuspid valve Surgery? • 55 year old female • No cardiovascular risk factors • Rheumatic mitral stenosis • In 2008 she underwent successful percutaneous mitral valve commissurotomy • Referred in 2013 with shortness of breath • Physical examination • • • • • NYHA functional class III Diastolic murmur at the apex Systolic murmur increasing during inspiration Right congestive heart failure Atrial fibrillation
  4. 4. The Mitral Valve Watch video Watch video Watch video Watch video Watch video Mitral valve area = 1.3 cm² Mean Gradient = 10 mm Hg
  5. 5. The Tricuspid Valve Watch video Watch video
  6. 6. What is you management strategy? 1.Repeat percutaneous mitral commissurotomy 2.Isolated mitral valve replacement 3.Combined mitral valve replacement tricuspid surgery (repair or replacement) + 4.More echocardiographic needed is information
  7. 7. What is you management strategy? 1.Repeat percutaneous mitral commissurotomy 2.Isolated mitral valve replacement 3.Combined mitral valve replacement tricuspid surgery (repair or replacement) + 4.More echocardiographic needed is information
  8. 8. What is you management ? 1.Repeat percutaneous mitral commissurotomy One commissure is completely open and MR grade is > 2 - mitral commissurotomy should no be performed 2.Isolated mitral valve replacement Severe tricuspid valve disease. Correction of leftsided disease does not cure the right side 3.Combined mitral valve replacement + tricuspid surgery (repair or replacement) 4.More echocardiographic needed information is
  9. 9. Same patient but different tricuspid disease… Watch video
  10. 10. What is you management strategy? 1.Repeat percutaneous mitral commissurotomy 2.Isolated mitral valve replacement 3.Combined mitral valve replacement tricuspid surgery (repair or replacement) + 4.More echocardiographic needed is information
  11. 11. What is you management strategy? 1.Repeat percutaneous mitral commissurotomy 2.Isolated mitral valve replacement 3.Combined mitral valve replacement tricuspid surgery (repair or replacement) + 4.More echocardiographic needed is information
  12. 12. Tricuspid annular diameter
  13. 13. Limitations of surgical strategy based only on degree of TR 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline Dreyfus G. Ann Thoarc Surg 2005; 79:127-132 Porter A. J Heart Valve Dis 1999; 8:57-62 Izumi C. J Heat Valve Dis 2002; 11:353-6 Predictive factors for the development of late severe TR - Age Ruel M. J Thorac Cardiovasc Surg 2004; 128:278-83 Song H. Circulation 2007; 116:I246-50 - Female gender Kim HK. Circulation 2005; 112:I14-9 - Atrial fibrillation Matsuyama. Ann Thorac Surg 2003; 75: 1826-8 Porter A. J Heart Valve Dis 1999; 8:57-62 - Pulmonary hypertension Vincens JJ. Circulation 1995; 92:II 137-42 - Rheumatic disease Levine MJ. Circulation 1989; 79:1061-7
  14. 14. Limitations of surgical strategy based only on degree of TR 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality
  15. 15. Limits of a surgical strategy only based on TR degree 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality 3. Surgery for isolated severe TR carries high morbidity and high mortality
  16. 16. Limits of a surgical strategy only based on TR degree 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality 3. Surgery for isolated severe TR carries high morbidity and high mortality Tricuspid annular diameter has been proposed as a more sensitive parameter to guide surgical indications for associated tricuspid valve surgery and to improve long-term morbidity and mortality
  17. 17. Strategy based on annular diameter • In 311 patients who underwent mitral valve repair a tricuspid annuloplasty was performed only if the tricuspid annular diameter measured during surgery was greater than twice the normal size (> 70 mm) regardless of the grade of regurgitation. Anteroseptal commissure Dreyfus GD et al. Ann Thorac Surg 2005; 79:127-32 Anteroposterior commissure
  18. 18. Strategy based on annular diameter • In 311 patients who underwent mitral valve repair a tricuspid annuloplasty was performed only if the tricuspid annular diameter was greater than twice the normal size (> 70 mm) regardless of the grade of regurgitation. • This strategy prevented the occurrence of severe late TR and improved the functional status irrespective of the grade of regurgitation. Dreyfus GD et al. Ann Thorac Surg 2005; 79:127-32
  19. 19. Comparison of a strategy based on TR degree alone OR TR degree and annular diameter • First cohort: 2002-2004. Associated TR surgery if TR ≥ grade 3 • Second cohort: 2004-2006. Associated TR surgery if TR ≥ grade 3 OR annular diameter ≥ 40 mm Van de Veire NR. J Thorac Cardiovasc Surg 2011;141:1431-9
  20. 20. Comparison of a strategy based on TR degree alone and TR degree and annular diameter • A strategy based on TR degree and tricuspid annular diameter for combined tricuspid valve surgery was associated with the absence of worsening of TR and the absence of negative right ventricular remodelling (enlargement) Van de Veire NR. JTCVS J Thorac Cardiovasc Surg 2011;141:1431-9
  21. 21. Associated tricuspid annuloplasty during mitral valve repair / replacement should be considered in patients with tricuspid annular dilatation despite the absence of significant TR to prevent the occurrence of right ventricular dysfunction and advanced heart failure TV annuloplasty adds little time to the surgery and is associated with very few complications
  22. 22. Guidelines on the management of valvular heart disease (version 2012) Vahanian et al. European Heart Journal 2012; 33(19):2451-2496 The best projection in which tricuspid annular diameter should be assessed remains debated but measurements are usually performed in the apical 4-chamber view.
  23. 23. TAKE HOME MESSAGES • During left-sided valve surgery, combined tricuspid valve surgery (annuloplasty or replacement) should be considered if TR grade > 2/4 or tricuspid annular diameter ≥ 40mm or ≥ 21mm/m² of body surface area - especially if predictors of occurrence of late TR are present (age, female gender, atrial fibrillation, pulmonary hypertension or rheumatic disease)
  24. 24. Join the ESC Working Group on Valvular Heart Disease and take part in its activities ! Membership is FREE!
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