The document discusses tricuspid valve intervention techniques. It describes Tricuspid Annular Plane Systolic Excursion (TAPSE) which measures tricuspid annular motion and is used to estimate right ventricular function. It discusses approaches to tricuspid valve repair including annuloplasty techniques using rings. It also discusses transcatheter therapies being developed for tricuspid regurgitation including annuloplasty devices and coaptation devices.

1. TRICUSPID VALVE
INTERVENTION TECHNIQUES.

2. TAPSE
TRICUSPID
ANNULAR
PLANE
SYSTOLIC
EXCURSION
What is TAPSE?
Measure in Apical 4 chamber view.
Advantages :
Less dependent on optimal image quality.
Simple method to estimate RV function.
A tricuspid annular excursion measurement
<1.6 cm is suggestive of RV dysfunction.*
*Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, Hahn RT, Han Y, Hung J, Lang RM, Little SH. Recommendations for
noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the
Society for Cardiovascular Magnetic Resonance. Journal of the American Society of Echocardiography. 2017 Apr 1;30(4):303-71.

6. Significant annular dilatation is defined by an
end-diastolic diameter of 40 mm or >21 mm/ m2
in the four-chamber transthoracic view and is
the main imaging criterion used to indicate
severe TR.

10. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

11. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

12. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

13. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

14. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

15. 2014 ACC/AHA GUIDELINES
Nishimura, RA et al.
2014 AHA/acc Valvular Heart Disease Guideline
2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
Nishimura RA et al. J Am Coll Cardiol. 2014; 63 (22):e56-185 Otto CM et al. J Am Coll Cardiol. 2021; 77 (4):e25-e197

16. 2020 ACC/AHA GUIDELINES
Otto et al.
2020 AHA/ACC Guidelines for the Management of Valvular Heart Disease
SEVERE TR DOPPLER MEASUREMENTS.

19. Why?
• Current treatment - diuretics, or surgery.
• Combined left and right heart valve surgery underutilized.
• As new devices are being tested in clinical trials, the assessment of
procedural success may be based in part on reduction in TR severity
similar to trials for mitral regurgitation.

20. SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for
Symptomatic Chronic Functional Tricuspid Regurgitation) trial
SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic
Chronic Functional Tricuspid Regurgitation) trial found on average, a reduction
in quantitative effective regurgitant orifice area (EROA) of 0.22± 0.29mm2
(the equivalent of a full grade). However the baseline quantitative EROA was
0.85± 0.22mm2 and the resulting EROA was 0.63± 0.29mm2. The current
grading schemes for TR thus fail to take into account the ‘torrential’ nature of
TR in the patients currently enrolling in these trials.

21. • Reduction in EROA : 0.22± 0.29mm2 (the equivalent of a
full grade).
• Baseline EROA : 0.85± 0.22mm2 (SEVERE TR)
• Resulting EROA : 0.63± 0.29mm2 (ALSO SEVERE TR)
• This decrease in TR was associated with an
increase in forward stroke volume, and resulted in
significant improvements in quality of life measures.
SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for
Symptomatic Chronic Functional Tricuspid Regurgitation) trial

22. • Not all severe TR patients will have the same
prognosis and new grades would be important
in determining outcomes in future trials.
• A new grading system was developed for
better assessment of procedural success.

23. INTERVENTION TECHNIQUES
The three fundamental principles of tricuspid valve
reconstruction are:
1. Restore or preserve full leaflet mobility.
2. Provide a large surface of leaflet coaptation.
3. Remodel and stabilize the annulus

24. APPROACH AND INTRAOPERATIVE VALVE ANALYSIS

26. PALLIATIVE ANNULOPLASTY
TECHNIQUES

29. RING SELECTION

31. TYPE I TRICUSPID REGURGITATION
Annular Remodeling

32. • The Classic ring is a cloth-
covered titanium semirigid
structure with maximal
flexibility in the axial
dimension
• The “Classic ring” model
consists of a short linear
segment corresponding to
the septal leaflet and a long,
curved segment
corresponding to the
anterior and posterior
leaflets.
• The “waveform” contour and
selective flexibility of the
different segments of the
Physio ring adapts to the
complex motion of the
annulus.
• Using magnetic resonance
imaging and extensive
anatomical studies on
beating hearts, a Physio
ring has been designed.

33. TYPE II TRICUSPID
REGURGITATION

34. EXTENSIVE PROLAPSE RESULTING FROM BACTERIAL
ENDOCARDITIS

35. EXTENSIVE CHORDAE RUPTURE

36. EXTENSIVE CHORDAE ELONGATION AND PAPILLARY MUSCLE
ELONGATION

37. PAPILLARY MUSCLE RUPTURE

38. TYPE IIIA TRICUSPID STENOSIS AND/OR REGURGITATION

39. TYPE IIIB TRICUSPID REGURGITATION

40. LESIONS CAUSED BY PACEMAKER OR DEFIBRILLATOR LEADS

41. TRANS CATHETER THERAPY
• As an alternative to valve replacement, three types of transcatheter
therapies have recently emerged for treating severe tricuspid
regurgitation:
– Heterotopic implant of a transcatheter valve at the level of the
vena cava.
– Devices dedicated to reduce tricuspid annular
dimensions(transcatheter tricuspid annuloplasty devices).
– Devices dedicated to improve tricuspid valve leaflet coaptation.

43. Anatomical Challenges in the Development of Transcatheter
Techniques Targeting Functional Tricuspid Regurgitation

44. HETEROTOPIC CAVAL TRANSCATHETER VALVE
IMPLANTATION
• OBJECTIVE-reduce the reflux into the vena
cavae and thereby improve symptoms and signs
of right heart failure
• CHALLENGES-
1. Large and variable diameters of VENA CAVAE
2. Length of the landing zone between the hepatic
veins and inferior cavo–right atrial junction

45. TRIC VALVE

46. Edwards SAPIEN XT or SAPIEN 3 valves

47. TRANSCATHETER TRICUSPID VALVE ANNULOPLASTY
Mitralign (Mitralign Inc,Tewksbury, MA, USA) / TriAlign
• This approach resembles a suture bicuspidization technique originally
described by Kay et al.
• Aims to reduce TR by obliterating the annular segment corresponding to the
posterior leaflet through placement of pledget-supported mattress sutures in
the annulus.

50. COAPTATION DEVICE

51. MitraClip

52. The MillipedeTM system

53. THANK YOU

66. Tricuspid stenosis : stages

67. Diagnosis and Follow-Up
•
Class I
1. TTE is indicated in patients with TS to assess the anatomy of the
valve complex, evaluate severity of stenosis, and characterize any
associated regurgitation and/or left-sided valve disease. (Level of
Evidence: C)
Class IIb
1. Invasive hemodynamic assessment of severity of TS may be
considered in symptomatic patients when clinical and non invasive
data are discordant. (Level of Evidence: C)

68. Intervention in tricuspid stenosis: aha
guidelines
Class I
1. Tricuspid valve surgery is recommended for patients with severe TS at
the time of operation for left-sided valve disease. (Level of Evidence: C)
2. Tricuspid valve surgery is recommended for patients with isolated,
symptomatic severe TS. (Level of Evidence: C)
Class IIb
1. Percutaneous balloon tricuspid commissurotomy might be considered
in patients with isolated, symptomatic severe TS without accompanying
TR. (Level of Evidence: C)

69. TRICUSPID STENOSIS
• Rheumatic tricuspid disease usually results in a regurgitant valve with
variable amounts of stenosis, but in rare cases theremay be pure stenosis.
In tricuspid stenosis, the orifice is larger than in mitral stenosis, even when
hemodynamicallythere is severe obstruction. Therefore, the hemodynamic
effects of anatomically moderate tricuspid stenosis are the equivalent of
tight mitral stenosis. A mean diastolic gradientof even 4 to 5 mmHg across
the tricuspid valve indicatesimportant stenosis. Borders of the stenotic
tricuspid orifice are usually fibrous and thickened, although peripheral
portionsof the leaflets remain thin. The hallmark of organic tricuspid
stenosis is commissural fusion. All commissures are usually equally fused,
but occasionallyfusion is limited to the anteroseptal commissure.Chordal
thickening and fusion are usually mild, and calcification is usually absent.

70. TRICUSPID STENOSIS
• Most common = Rheumatic.
• Other causes include
– Congenital tricuspid atresia;
– Right atrial tumors.
– Device leads, which more often are associated with tricuspid regurgitation (TR) but can become looped and fused to the tricuspid valve
apparatus, and if multiple could cause obstruction.
– The carcinoid syndrome and use of ergot- related drugs more frequently produce TR, which if severe, contributes to a gradient across the
tricuspid valve.
– Dysfunction, including thrombosis, of a tricuspid mechanical or bioprosthetic valve can result in stenosis.
– Rarely, endomyocardial fibrosis,
– Tricuspid valve vegetations, or extracardiac tumors cause obstruction to right ventricular (RV) inflow.
– Localized compression of the right atrium by a pericardial effusion may also lead to RV inflow obstruction.
– Isolated rheumatic TV disease is rare.
– Most patients with rheumatic tricuspid valve disease have TR or a combination of TS and TR. Isolated rheumatic tricuspid valve disease is
uncommon, and this lesion generally accompanies mitral valve disease, which dominates the presentation. In many patients with TS, the
aortic valve also is involved (i.e., trivalvular stenosis is present). TS is found at autopsy in approximately 15% of patients with rheumatic heart
disease but is of clinical significance in only approximately 5%.

71. – Organic tricuspid valve disease is more common in India, Pakistan, and
other developing nations near the equator than in North America or
Western Europe. The anatomic changes of rheumatic TS resemble
those of mitral stenosis (MS), with fusion and shortening of the
chordae tendineae and fusion of the leaflets at their edges, producing
a diaphragm with a fixed central aperture, typically without
calcification. Like MS, TS is more common in women. The right atrium
often is greatly dilated in TS, and its walls are thickened.
– There may be evidence of severe passive congestion, with
enlargement of the liver and spleen, and right atrial thrombus
formation which may extend into the vena cava or cause pulmonary
embolism.

72. PATHOPHYSIOLOGY
• Pathophysiology A diastolic pressure gradient between the right atrium and ventricle—is augmented
when the transvalvular blood flow increases during inspiration or exercise and is reduced when the
blood flow declines during expiration. A relatively modest diastolic pressure gradient (i.e., a mean
gradient of only 5 mmHg) usually is sufficient to elevate the mean right atrial pressure to levels that
result in systemic venous congestion and, unless sodium intake has been restricted or diuretics have
been given, is associated ultimately with jugular venous distention, ascites, and edema.
• In patients with sinus rhythm, the right atrial a wave may be very tall. Resting cardiac output usually is
markedly reduced and fails to rise during exercise. This accounts for the normal or only slightly
elevated left atrial, pulmonary arterial, and RV systolic pressures, despite the frequent presence of
accompanying mitral valvular disease. A mean diastolic pressure gradient across the tricuspid valve as
low as 2 mmHg and the typical echocardiographic appearance of leaflet restriction or doming is
sufficient to establish the diagnosis of TS. Exercise, deep inspiration, and the rapid infusion of fluids or
the administration of atropine may greatly enhance a borderline pressure gradient in a patient with
TS. The diagnosis is generally made with transthoracic echocardiography; occasionally,
transesophageal echocardiography (TEE) or other imaging such as cardiac magnetic resonance
imaging (CMR) or computed tomography (CT) is necessary. Invasive assessment is rarely necessary.

75. RING IMPLANTATION
• 3-0 horizontal mattress sutures are placed at
equidistant points around the tricuspid annulus.
• The leaflet tissue must be grasped transversally
and pulled away from its attachment to visualize
its hinge.
• The first septal suture should be placed through
the hinge of this leaflet to prevent injury to the
bundle of His.
• The following septal mattress suture is placed in
the same manner towards the posteroseptal
commissure. Directing the needle through the
annulus toward the ventricular cavity and then
back through the annulus ensures that these bites
have maximal strength.

77. • Sutures are then passed
through the sewing band.
• Equal spacing is used for
sutures of the septal leaflet
while reduced spacing is used
for sutures that arise from the
posterior and anterior leaflets.
• The prosthetic ring is lowered
into position, thus remodelling
the annulus and ensuring the
adequate surface of coaptation
while preserving full mobility of
the leaflets.
• The normal geometry of the
closure line is tested by using a
bulb syringe to inject saline
solution into the ventricular
cavity.