The document discusses when to consider tricuspid valve repair. Tricuspid regurgitation is associated with poor prognosis, especially when secondary to left-sided heart lesions, cardiomyopathy, pulmonary hypertension, or in the setting of LVAD placement or heart transplantation. Tricuspid valve repair is indicated for severe, symptomatic primary tricuspid regurgitation, and may also be considered for significant functional regurgitation concurrent with mitral valve surgery, after isolated mitral valve surgery if regurgitation is severe, or when placing a continuous-flow LVAD. Prophylactic tricuspid annuloplasty during heart transplantation reduces the severity of post-operative regurgitation and is associated with improved long-term survival

1. When To Consider Tricuspid Valve Repair
V. Jeevanandam, M.D.

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The “ignored” valve
• Rarely affected in isolation
• Manifestations are extra-cardiac
– Peripheral edema
– Liver congestion… ascites
– Renal dysfunction by decreasing transrenal gradient
• Low pressure so hard to evaluate; volume dependent
• TR associated with poor prognosis in:
– Primary: endocarditis, iatrogenic, rheumatic, carcinoid, myxomatous
– Functional : left sided lesions, cardiomyopathy, pulmonary HTN
– LVADs
– Transplantation
• Does repairing the TR make a difference?

3. • Three leaflets
– Ant > post > septal
• Three clefts – do not
extend to annulus
• Annulus not a fixed
structure
– Anterior and posterior
attached to RV free wall
– Dynamic with change in
orifice area during
cardiac cycle
– Saddle shaped to
decrease leaflet stress
Fibrous skeleton - closed AV valves
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TV abnormalities – primary
- Symptomatic
- Preserved RV function:
low RVEDP
- Low PA pressures

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TV abnormalities – primary
• Stenosis
– Rheumatic
– Carcinoid
– Appetite suppressing drugs

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TV abnormalities – primary
• Regurgitation
– Endocarditis
• IVDA
• Hemodialysis
• Pacing leads
– Trauma
– Myxomatous
– Post-infarction

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TV abnormalities – primary
• Regurgitation
– Iatrogenic
• Pacemakers and ICD
• Transplant biopsies
• TIPPS catheters
• In-dwelling lines

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3D Echo
PostAnt

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10. Postoperative 3DE
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11. DeVega
annuloplasty
and tricuspid
valve annulus
Ruptured chordae
Septal
leaflet
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12. PTFE chordal
reconstruction
*
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TV abnormalities – functional
• Annular dilation
– Perimeter increase 100-120 to >150mm
– Diameter >40mm
– Asymmetric
• Basis of repair
• RV dysfunction
– Pressure, volume overload
• Pulmonary hypertension
• Left sided lesions
– Infarction
– LVAD placement
• Prognosis depends on RV function
• Treatment: reduction annuloplasty
– Suture DeVega
– Rigid ring

15. 2D ECHO annulus dilation
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16. 3D for TC annulus dilation
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Functional TR: TVA concomitant with MV
surgery
• Guidelines
•

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TVA concomitant with MV Surgery
• Why? Raja, Dreyfus. Basis for Intervention on Functional TR.
Semin Thoracic Surg 22:79-83
• TR does not improve after MV procedure – especially if
annulus dilated >4cm
• Actually worsens
• Survival benefit not proven

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Functional TR: TVA reoperation after MV
Surgery
• Kim, Kwon, Kim, et al. Determinants of surgical outcome in
patients with isolated TR. Circulation 2009; 120:1672-8
• 61 patients with TR after left sided procedure
• Favors
– Concomitant procedure
– Earlier TVA before cardiac deterioration – marker for worsening RV
NYHA class % patients Event free 1 yr Event free 2 yr
II 34 95 90
III, IV 66 73 68

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TR repair: Concomitant with cfLVAD
• Saeed, Kidambi, Shalli, McGee, et al. TV repair with LVAD: is it
warranted? JHLT 2011;30:530
– 72 LVADs, 42 > 3+ TR, 8 repaired / 34 no repair
– No benefit from TVR
– TVR : longer CPB, more blood, higher BUN / crt.
– Small study, selection bias
• Maltais, Topilsky, Park, et al. Surgical treatment of TR promotes early
reverse remodeling in patients with cfLVAD. JTCVS 2012;143:1370
– 83 HMII, 37 severe TR (32 repair, 5 replacement)
– TR group worse – more TR vena contracta, more RV dysfunction (RVEDA),
higher RA pressure, higher Kormos score, more IABP
– 30 days in TVR group – TR better than in LVAD only group (-50.2% vs 18.6% );
more RVEDA reduction
– Survival and RVF similar although TR group sicker

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TR repair: Concomitant with cfLVAD
• Piacentino, Rogers, Milano, et al. Utility of concomitant TV procedures
for patients undergoing cfLVADs. JTCVS 2012;144:1217-21
– 200 consecutive LVADs; 61 significant TR (3 or 4+); 33 cfLVAD + TVP with 28
just receiving cfLVAD
• Summary: for cfLVAD, repairing TV improves RV function an decreases TR
but without statistically significant survival benefit

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Prophylactic TVA with heart transplantation
• Significant TR after HT reported from 10-60%.
– Depends on bicaval/total vs biatrial; RV function; pulmonary hypertension
– TR associated with worse survival
• Jeevanandam, et al. Prophylactic TV DeVega Annuloplasty during
heart transplantation. Ann Thor Surg 2004 78(3):759-66
– Randomized controlled trial – bOHT vs. bOHT + TVA; 30 patients in each arm
– Donor and recipient demographics similar
– Followed out to 6 years

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Results: severity of TR
Group Avg. ≤ 1 2 ≥ 3 % > 2
Intra-operative A 1.1 ± 1.0 21 5 4 30.0%
B .33 ± .38 30 0 0 0.0%
p=0.01 p=0.01
1 Week A 0.6 ± 0.9 24 2 1 11.1%
B 0.4 ± 0.6 28 2 0 6.7%
ns ns
1 Month A 1.0 ± 0.9 20 4 2 23.1%
B 0.3 ± 0.7 28 1 1 6.7%
p=0.006 p=0.05
1 Year A 1.3 ± 1.0 17 7 2 34.6%
B 0.2 ± 0.3 27 0 0 0.0%
p=0.01 p=0.02
6 Years A 1.5 ± 1.3 14 2 6 36.4%
B 0.5 ± 0.4 22 0 0 0.0%
p=0.01 p=0.02
Mann Whitney U test

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Is there a correlation between >2+ TR and
death?
Survival Functions
MO_ALIVE
120100806040200-20
1.1
1.0
.9
.8
.7
.6
.5
.4
TR2
1.00
1.00-censored
.00
.00-censored
Yes: log rank p=0.005

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Results: renal function
Group BUN Crt dCrt
Pre-operative A 22.3 ± 11.5 1.02 ± .3
B 26.8 ± 15.6 1.34 ± .7
ns p=0.058
1 Week A 45.6 ± 28.9 1.21 ± .6 .2 ± .6
B 40.2 ± 29.6 1.5 ± 1.3 .2 ± 1.5
ns ns ns
1 Month A 33.6 ± 12.4 1.2 ± .6 .2 ± .7
B 33.2 ± 12 1.3 ± .5 0 ± .8
ns ns ns
1 Year A 42.5 ± 16.5 2.3 ± 1.3 1.3 ± .9
B 37.7 ± 15 2.2 ± 1 1.1 ± .9
ns ns p=0.061
6 Years A 41.0 ± 14.4 2.9 ± 2.0 2.0 ± 2.0
B 32.3 ± 12.1 1.8 ± 0.7 0.7 ± .8
ns p=0.04 p=0.02

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Is there a correlation between TR >2+ and
creatinine >2.5?
AVG_TR
543210-1
CREAT 10
8
6
4
2
0
DEVEGA
1.00
.00
Yes: Fisher exact p=0.002

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Summary
• Increased appreciation of tricuspid valve
– Regurgitation and chronic high CVP associated with decreased
survival
– Renal / hepatic dysfunction, edema, ascites
• Repair technique:
– rigid annuloplasty most durable
– Suture reasonable for prophylactic or normal PA pressures
• Primary TV repair indicated if severe and symptomatic (Class
IIa, evidence C)
• Functional TR (>3+) or annulus greater than 4cm
– With MV surgery (class I, evidence B)
– Isolated, after MV surgery, no PulmHTN (ESC – class IIaC). NYHA 3, 4
poor 2 year event free survival
– cfLVAD: decrease RV failure, better RV remodeling, no survival benefit
• TVA with HT – survival and renal benefit.

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Papillary Muscle and Chordae
• Marginal chords attached to free margin
– Prevent regurgitation
• Basal chords attached to body
– Maintain structure of RV
• Ant, post papillary muscle and septal band

31. ECHO - Normal tricuspid
function
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Surgeons view