1. When to perform
Tricuspid valve
Surgery?
Julien Dreyfus MD and
David Messika-Zeitoun MD, PhD
Bichat Hospital, Paris, France

2. When to perform Tricuspid valve Surgery?
• A case by the ESC Working Group on Valvular Heart Disease

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. The Mitral Valve
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video
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video
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Mitral valve area =
1.3 cm²
Mean Gradient = 10 mm Hg

5. The Tricuspid Valve
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video
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video

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. 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. 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. Same patient but
different tricuspid
disease…
Watch video

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. 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. Tricuspid annular
diameter

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!