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Cardio Update

Tricuspidalklappe: The Forgotten ValveRaban Jeger, Oliver Reuthebuch

Kardiologie

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• Valvular heart disease

• Moderate aortic and mitral regurgitation, mildly reduced LVEF (48%)

• Severe tricuspid regurgitation, dilated right ventricle with reduced RVEF

(TAM 13mm, FAC 24%)

• Atrial fibrillation

• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III

• Refuses surgery

Clinical Case 1

Female Patient, 83 Years

Valvular heart disease

• Aortic valve replacement (ATS 20 mm) 2002, endocarditis 2008, re-do-surgery

with aortic valve replacement (Perimount Magna Ease 21 mm) and tricuspidal

repair (Edwards 4900 26 mm MC3 tricuspid annuloplasty ring) 2009

• Mild mitral stenosis and moderate mitral regurgitation, LVEF 60%

• Severe tricuspid stenosis (RV/RA Gradient: 33 mmHg) and severe regurgitation,

PAHT 45 mmHg, dilated right ventricle with slightly decreased RVEF

Single-vessel coronary disaese

• CABG SVG-RCA 2009

Atrial fibrillation

• DDD-PM 2009, battery replacement 2018

M. Hodgkin 1965

• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III

• High surgical risk

Clinical Case 2

Female Patient, 70 Years

Anatomie

Anatomie

Anatomie

Anatomie

Chirurgische Anatomie (Sternotomie)

Chirurgische Anatomie (Sternotomie)

Chirurgische Anatomie (Sternotomie)

Chirurgische Anatomie (ant.-lat.)

Chirurgische Anatomie (ant.-lat.)

Surgical Techniques

Surgical Techniques

Surgical Techniques

«Clover Technique»

Surgical Techniques

«Pericardial Enlargement» «Double Orifice»

Surgical Techniques

Surgical Techniques

Tricuspid Valve

Prevalence and Surgery

Stuge O., Liddicoat J., et al. JTCS 2006;132:1258-61

22%

63%

0.5%

Temporal trend of isolated tricuspid valve surgery for secondary tricuspid regurgitation in the

USA between 2003 and 2014.

Mohamad Alkhouli et al. Open Heart 2018;5:e000878

Results

Results

Mohamad Alkhouli et al. Open Heart 2018;5:e000878

Results

Results

Tricuspid Valve Regurgitation

Classification and Cause

Rodes-Cabau J et al, Lancet 2016; 388: 2431–42

Tricuspid Valve Regurgitation

Pathophysiology

Deloche et al. Ann Chir Thorac Cardiovasc 1973

Shaikhrezai, et al. Ann Thorac Surg 2017

Functional

(asymmetric

annular

dilatation)

Iatrogenic

(Pacemaker)

Structural

Tricuspid

Regurgitation

Functional Tricuspid Valve Regurgitation

Pathophysiology

Tornos Mas P, Rodríguez-Palomares JF, Antunes MJ. Heart 2015;101:1840–1848

Tricuspid Valve Regurgitation

Regurgitation and Mortality

Nath J et al, J Am Coll Cardiol 2004;43:405–9

Tricuspid Valve Regurgitation

Diagnosis of Severe Valve Regurgitation

Baumgartner H et al, European Heart Journal (2017)38, 2739–2791

Functional Tricuspid Regurgitation

Classification and Treatment

Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6.

ESC Guidelines on Valvular Heart Disease 2017

Regurgitation: Indications for Tricuspid Surgery

Baumgartner H et al, European Heart Journal (2017)38, 2739–2791

Baumgartner H et al, European Heart Journal (2017)38, 2739–2791

ESC Guidelines on Valvular Heart Disease 2017

Indications for Tricuspid Surgery

Severe Functional Tricuspid Regurgitation

Indications for Tricuspid Surgery

Tornos Mas P, Rodríguez-Palomares JF, Antunes MJ. Heart 2015;101:1840–1848

Too Bad Too Good

Symptoms

LVEF

PAHT

• Tricuspid regurgitation is frequent but somewhat difficult to define

• Surgery clearly indicated for good candidates

• Options for „bad“ candidates?

• Surgical mortality higher than for any other valve surgery

• Early prophylactic intervention at the time of left sided disease useful

• As more left side valve disease are getting transcatheter interventions the

negative impact of tricuspid regurgitation on these patients underscores the need

to develop solutions

Tricuspid Valve Regurgitation

Considerations for Transcatheter Therapy

Tricuspid Regurgitation

Interventional Options

Asmarats, L. et al. J Am Coll Cardiol. 2018;71(25):2935–56

Tricento

Forma, TricuClip

Cardioband

Tricinch, Trialign

Tricuspid Regurgitation

The TriValve Registry: Interventional Options

Taramasso M et al, JACC Cardiovasc Interv. 2019 Jan 28;12(2):155-165.

Interventional Options for Tricuspid Regurgitation

TricuClip: Edge-to-Edge Repair

Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814

Interventional Options for Tricuspid Regurgitation

TricuClip: Edge-to-Edge Repair

Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814

• 400 cases performed worldwide

• Transfemoral approach

• Usually 1-2 clips on antero-septal leaflets

(easiest to reach); medial clip has better

results than commissural clip but not always

feasible

• TEE is standard and superior to ICE

• Patient selection is important

• Challenges:

• Leaflets are more fragile, larger

coaptation gap

• Imaging not standardized

• New device with longer arms and a tricuspid

delivery system are needed

Interventional Options for Tricuspid Regurgitation

Tricuclip: Edge-to-Edge Repair

Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814

Interventional Options for Tricuspid Regurgitation

Trialign: The Scout Trial

Hahn RT et al, J Am Coll Cardiol. 2017 Apr 11;69(14):1795-1806

Interventional Options for Tricuspid Regurgitation

Tricinch

Rosser BA et al, EuroIntervention 2016;12:Y110-Y112

Anterior annulus

of the tricuspid

valve, in

proximity to the

anteroposterior

commissure

Interventional Options for Tricuspid Regurgitation

Cardioband Tricuspid

Schueler R et al, JACC Cardiovasc Interv. 2017 Feb 27;10(4):415-416

• Adjusted

transfemoral

Cardioband

• Proven safety and

performance with

over 90 mitral

patients

• Quick learning

curve to

Cardioband users

• Applying the

surgical gold

standard with a

transfemoral

approach

• Valvular heart disease

• Moderate aortic and mitral regurgitation, mildly reduced LVEF (48%)

• Severe tricuspid regurgitation, dilated right ventricle with reduced RVEF

(TAM 13mm, FAC 24%)

• Atrial fibrillation

• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III

• Refuses surgery

Clinical Case 1

Female Patient, 83 Years

Cardioband Tricuspid (Female Patient, 83 Years)

Cardioband Tricuspid (Female Patient, 83 Years)

Cardioband Tricuspid (Female Patient, 83 Years)

Interventional Options for Tricuspid Regurgitation

Forma

Campelo-Parada F et al, Am Coll Cardiol 2015;66:2475–83

Interventional Options for Tricuspid Regurgitation

Forma

Perlman G et al, JACC Cardiovasc Interv. 2017 Oct 9;10(19):1994-2003

Interventional Options for Tricuspid Regurgitation

Valve-in-Ring, Valve-in-Valve

Valvular heart disease

• Aortic valve replacement (ATS 20 mm) 2002, endocarditis 2008, re-do-surgery

with aortic valve replacement (Perimount Magna Ease 21 mm) and tricuspidal

repair (Edwards 4900 26 mm MC3 tricuspid annuloplasty ring) 2009

• Mild mitral stenosis and moderate mitral regurgitation, LVEF 60%

• Severe tricuspid stenosis (RV/RA Gradient: 33 mmHg) and severe regurgitation,

PAHT 45 mmHg, dilated right ventricle with slightly decreased RVEF

Single-vessel coronary disaese

• CABG SVG-RCA 2009

Atrial fibrillation

• DDD-PM 2009, battery replacement 2018

M. Hodgkin 1965

• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III

• High surgical risk

Clinical Case 2

Female Patient, 70 Years

TAVI-in-Ring Tricuspid (Female Patient, 70 Years)

TAVI-in-Ring Tricuspid (Female Patient, 70 Years)

Interventional Options for Tricuspid Regurgitation

Tricento

Toggweiler S et al, EuroIntervention. 2018 Sep 20;14(7):758-761

• Bicavally anchored

custom made

covered stent

• Thin porcine

pericardium

leaflets

• Radiopaque

markers for safe

positioning

• Aims to abolish

systolic backflow

in inferior and

superior caval

veins

Interventional Options for Tricuspid Regurgitation

Tricento

Lausberg, HF. European Journal of Cardio-Thoracic Surgery 0 (2017) 1–8

Interventional Options for Tricuspid Regurgitation

Tricento

Lausberg, HF. European Journal of Cardio-Thoracic Surgery 0 (2017) 1–8

Tricento

Tricento

Tricento

• High-risk patients with high perioperative surgery

• Open issues: Indication, patient selection, imaging, assessment of outcomes

• Individual decision on treatment and modality

• Transcatheter tricuspid therapy is feasible with different techniques – their clinical

efficacy is still to be determined

Tricuspid Valve Disease

Take Home Messages

Thank you

for your attention

raban.jeger@usb.ch

oliver.reuthebuch@usb.ch

Tricuspid Valve

Anatomy

Kardiologie

AV node

Rodes-Cabau J et al, Lancet 2016; 388: 2431–42

Tendon of Todaro

Koch‘s

Triangle

Transcatheter Treatment of AV Valves

Comparison Mitral - Tricuspid

Kardiologie

Courtesy F. Maisano

Functional Tricuspid Regurgitation

Development, Assessment, Diagnosis, and Treatment

Kardiologie

Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6.