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Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling , MD Professor of Cardiac Surgery University of Michigan

Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

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Page 1: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data

Steven F Bolling MD Professor of Cardiac Surgery

University of Michigan

Is FTR important Decreased CO

Fatigue decreased exercise toleranceldquoRight-sidedrdquo Heart Failure

Ascites edema decreased appetite fullness

FTR patients feel terrible

Valve repair for functional tricuspid valve regurgitationanatomical and surgical considerations

Rogers JH Bolling SF Semin Thorac Cardiovasc Surg 2010 22(1)84-9

hellipand FTR patients die FTR increases Mortality

Nath JACC 200443405

5223 pts Severe and Moderate TR increase mortality independent of PASP LVEF IVC size RV size function

Severe and MODERATE FTR Decreases Survival

TR is bad TR hurts quality of life and QUANTITYTopilsky JACC 2014

Fukuda Circulation 2006114I-492

Normal Tricuspid Annulus Tricuspid Annulus with Functional TR

Annular Dilation Shape Change of FTR

75- all cases of MR

-40

-20

0

20

40

-40 -20 0 20 40

-40

-20

0

20

40

-40 -20 0 20 40

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904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
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Page 2: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Is FTR important Decreased CO

Fatigue decreased exercise toleranceldquoRight-sidedrdquo Heart Failure

Ascites edema decreased appetite fullness

FTR patients feel terrible

Valve repair for functional tricuspid valve regurgitationanatomical and surgical considerations

Rogers JH Bolling SF Semin Thorac Cardiovasc Surg 2010 22(1)84-9

hellipand FTR patients die FTR increases Mortality

Nath JACC 200443405

5223 pts Severe and Moderate TR increase mortality independent of PASP LVEF IVC size RV size function

Severe and MODERATE FTR Decreases Survival

TR is bad TR hurts quality of life and QUANTITYTopilsky JACC 2014

Fukuda Circulation 2006114I-492

Normal Tricuspid Annulus Tricuspid Annulus with Functional TR

Annular Dilation Shape Change of FTR

75- all cases of MR

-40

-20

0

20

40

-40 -20 0 20 40

-40

-20

0

20

40

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979290747947
913779502576
825114311281
787747668089
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634225640215
599663941193

Chart2

-14333781419
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27822404151
12007277087
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Sheet1

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ED
ES
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0
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Sheet2

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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
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Page 3: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

hellipand FTR patients die FTR increases Mortality

Nath JACC 200443405

5223 pts Severe and Moderate TR increase mortality independent of PASP LVEF IVC size RV size function

Severe and MODERATE FTR Decreases Survival

TR is bad TR hurts quality of life and QUANTITYTopilsky JACC 2014

Fukuda Circulation 2006114I-492

Normal Tricuspid Annulus Tricuspid Annulus with Functional TR

Annular Dilation Shape Change of FTR

75- all cases of MR

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ED
4
5
6
7
8
9
ES
X-Z plane
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913779502576
825114311281
787747668089
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680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
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979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
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276245542685
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106291601476
80711897756
27822404151
12007277087
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-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
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Sheet2

Sheet3

05876977367
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4
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ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
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4
5
6
7
8
9
ES
Y-Z plane
979290747947
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
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Page 4: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Severe and MODERATE FTR Decreases Survival

TR is bad TR hurts quality of life and QUANTITYTopilsky JACC 2014

Fukuda Circulation 2006114I-492

Normal Tricuspid Annulus Tricuspid Annulus with Functional TR

Annular Dilation Shape Change of FTR

75- all cases of MR

-40

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120254632691
99721457036
191263214987
187718399817
192328453309
203354827871
168821684706
19423632711
201535401914
171178669966
243101540178
241914273209
234329184933
259628676125
222814160851
263685913142
266307765481
233925693679
274022641715
271682601998
242555584319
275966170956
251606560343
289454293134
288165866473
264659148883
268305801613
259689876921
216653864225
245988012703
240468620862
256928889391
255552951404
247175082556
217568277546
202879605084
164267994531
179246558452
186506126669
17887323146
180866058419
185111488732
131111960188
117978567573
96536503502
95975425563
103592077393
87491815597
9239266766
100857749979
34228417088
31627463314
23960394594
16640883112
16447911216
12614751883
15733108747
2100375707
-45981099105
-3676826918
-45021331702
-46390321178
-52625173518
-35708999614
-3980953506
-3949446103
-9617816235
-84616210167
-103435925205
-90331233421
-94552135835
-66640710409
-79770111414
-81673733266
-121026326459
-120571150061
-145454133355
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-114127045934
-93165576259
-111984546229
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-133438907215
-150479111794
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-13159308096
-1214265091
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-140486256835
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-123139169233
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-125351248578
-132852560031
-142823483521
-115118954432
-128833149291
-123117457791
-101588340924
-94557051383
-99882297897
-102685071866
-113804366339
-69077246382
-70604704586
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-67657371798
-59630190633
-62608453497
-61906149326
-70682117613
-05876977367
-03229358468
-20394345834
-18727874802
-12254164167
-18043997938
-13801236595
-2080268363
ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
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1042713199654
984433244397
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904037456604
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831835885924
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1014636795116
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853215860433
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549269837143
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730552468751
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607678404055
584336598146
576748843136
518227284972
804326532071
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671807365975
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600366101814
56715160314
526222424581
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806564474405
763430356667
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612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
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677689404639
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935951484467
889104522167
812458521258
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671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
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849265913122
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721247407131
679337594802
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587657818332
1009712978745
934207315996
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856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
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920090103091
885598657653
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627851394652
1042713199654
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904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
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81024849353
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706388901446
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637831121746
624716088582
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780782176574
751905041551
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591358715289
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651983621581
623936064908
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885949323766
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671597868957
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913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
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Page 5: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Fukuda Circulation 2006114I-492

Normal Tricuspid Annulus Tricuspid Annulus with Functional TR

Annular Dilation Shape Change of FTR

75- all cases of MR

-40

-20

0

20

40

-40 -20 0 20 40

-40

-20

0

20

40

-40 -20 0 20 40

Chart3

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ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
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885949323766
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610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
239213835387
22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
243101540178
241914273209
274022641715
271682601998
268305801613
259689876921
217568277546
202879605084
131111960188
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34228417088
31627463314
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Sheet2

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05876977367
2080268363
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4
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9
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191263214987
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19423632711
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4
5
6
7
8
9
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X-Z plane
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Y-Z plane
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
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-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
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75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
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-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
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221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
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08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
x-ft x-ft
-2212921873 -2044349067
-237626439 -2179641184
-2154410172 -2019974617
-1474464567 -1437960459
-4164729804 -451461207
7565474164 6951134457
1696001042 1625839052
2147746939 2055635702
2087413663 1964478499
1706936177 1578059694
1263924629 1174279981
9127607086 8825441865
6410534119 6372581287
3378275489 2987247802
-0870639766 -1918366841
-6350843845 -7654582209
-1235249446 -1304154016
-1793740377 -1736944457
x-ft y-ft z-ft x-ft y-ft z-ft
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
78971395061 130321103309 1007977901068 93553704809 135233393779 898194735069 -78971395061 -130321103309 -93553704809 -135233393779
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Page 6: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart3

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Chart2

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Sheet1

Sheet1

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920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
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Page 7: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
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Page 8: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

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ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
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885949323766
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610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
239213835387
22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
243101540178
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274022641715
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259689876921
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Sheet2

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05876977367
2080268363
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4
5
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7
8
9
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X-Z plane
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Y-Z plane
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
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-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
-75654741645 -57309481748
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08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
x-ft x-ft
-2212921873 -2044349067
-237626439 -2179641184
-2154410172 -2019974617
-1474464567 -1437960459
-4164729804 -451461207
7565474164 6951134457
1696001042 1625839052
2147746939 2055635702
2087413663 1964478499
1706936177 1578059694
1263924629 1174279981
9127607086 8825441865
6410534119 6372581287
3378275489 2987247802
-0870639766 -1918366841
-6350843845 -7654582209
-1235249446 -1304154016
-1793740377 -1736944457
x-ft y-ft z-ft x-ft y-ft z-ft
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
78971395061 130321103309 1007977901068 93553704809 135233393779 898194735069 -78971395061 -130321103309 -93553704809 -135233393779
124335968095 113875343787 1015784038439 144990276975 123005410379 911533231381 -124335968095 -113875343787 -144990276975 -123005410379
160906165418 83838326776 1007381376667 177243362817 95935148128 91524687888 -160906165418 -83838326776 -177243362817 -95935148128
190289540028 27344482344 989856046861 189800830761 42608371525 914502141473 -190289540028 -27344482344 -189800830761 -42608371525
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146495267958 -233871439232 986889629267 115397905403 -224479093749 935655467687 -146495267958 233871439232 -115397905403 224479093749
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634225640215
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ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
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680226372768
634225640215
599663941193
1001229079308
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979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
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277122500416
272257489961
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80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
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Sheet2

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05876977367
2080268363
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4
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ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
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787747668089
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680226372768
634225640215
599663941193
1001229079308
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4
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Y-Z plane
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599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
-75654741645 -57309481748
-169600104246 -14271742887
-214774693926 -183982330079
-208741366314 -173172742737
-170693617732 -133498355845
-126392462901 -9803061908
-9127607086 -81477679599
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4
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Y-Z plane
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Chart2

-14333781419
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Sheet1

Sheet1

ED
ES
0
0
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Sheet2

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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
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Page 11: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
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664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
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Page 12: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
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614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
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ED
4
5
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7
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ES
Y-Z plane
979290747947
913779502576
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885949323766
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610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
239213835387
22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
243101540178
241914273209
274022641715
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31627463314
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Sheet2

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05876977367
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4
5
6
7
8
9
ES
X-Z plane
979290747947
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825114311281
787747668089
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634225640215
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4
5
6
7
8
9
ES
Y-Z plane
979290747947
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634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
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75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
Page 14: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
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610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
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57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
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22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
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-93529361012
-14226875881
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-14333781419
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Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
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Sheet2

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05876977367
2080268363
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5
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X-Z plane
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4
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Y-Z plane
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
-75654741645 -57309481748
-169600104246 -14271742887
-214774693926 -183982330079
-208741366314 -173172742737
-170693617732 -133498355845
-126392462901 -9803061908
-9127607086 -81477679599
-64105341193 -70759153016
-33782754889 -41868440645
08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
x-ft x-ft
-2212921873 -2044349067
-237626439 -2179641184
-2154410172 -2019974617
-1474464567 -1437960459
-4164729804 -451461207
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3378275489 2987247802
-0870639766 -1918366841
-6350843845 -7654582209
-1235249446 -1304154016
-1793740377 -1736944457
x-ft y-ft z-ft x-ft y-ft z-ft
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
78971395061 130321103309 1007977901068 93553704809 135233393779 898194735069 -78971395061 -130321103309 -93553704809 -135233393779
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196459813393 -153124889252 977553515199 160745277178 -13811966148 927886773251 -196459813393 153124889252 -160745277178 13811966148
146495267958 -233871439232 986889629267 115397905403 -224479093749 935655467687 -146495267958 233871439232 -115397905403 224479093749
58652508711 -277122500416 994361396641 48396760253 -272257489961 930429787136 -58652508711 277122500416 -48396760253 272257489961
-46324177435 -276245542685 993670631365 -31654055086 -269611895562 909937127266 46324177435 276245542685 31654055086 269611895562
-138258220816 -239213835387 98868763227 -108077305473 -22410848541 884270927189 138258220816 239213835387 108077305473 22410848541
-194461227149 -179146271838 988106267463 -163773510776 -154968035054 867849318539 194461227149 179146271838 163773510776 154968035054
-210652032096 -106291601476 995154626023 -190005793829 -80711897756 867060320248 210652032096 106291601476 190005793829 80711897756
-197974753618 -27822404151 1003379939044 -189079640356 -12007277087 875368531514 197974753618 27822404151 189079640356 12007277087
-170438339716 47468943594 1003155821306 -169150760352 46978640854 880465165201 170438339716 -47468943594 169150760352 -46978640854
-134636022002 107514814377 992335030466 -136443799202 93529361012 876358495915 134636022002 -107514814377 136443799202 -93529361012
-89747799628 14226875881 979875440936 -92033256614 124499793527 868674335351 89747799628 -14226875881 92033256614 -124499793527
-35128961091 151043227866 978072397327 -35410190772 138987834304 868319106901 35128961091 -151043227866 35410190772 -138987834304
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
-24022164913 -29677353199
-78971395061 -93553704809
-124335968095 -144990276975
-160906165418 -177243362817
-190289540028 -189800830761
-206815591073 -184509550333
-196459813393 -160745277178
-146495267958 -115397905403
-58652508711 -48396760253
46324177435 31654055086
138258220816 108077305473
194461227149 163773510776
210652032096 190005793829
197974753618 189079640356
170438339716 169150760352
134636022002 136443799202
89747799628 92033256614
35128961091 35410190772
-24022164913 -29677353199
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
Page 15: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
239213835387
22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
243101540178
241914273209
274022641715
271682601998
268305801613
259689876921
217568277546
202879605084
131111960188
117978567573
34228417088
31627463314
-45981099105
-3676826918
-9617816235
-84616210167
-121026326459
-120571150061
-133438907215
-150479111794
-140486256835
-168877088223
-137618230663
-163751723919
-115118954432
-128833149291
-69077246382
-70604704586

Sheet2

Sheet3

05876977367
2080268363
-63145903326
-34906659277
-129884842743
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121026326459
113662349613
133438907215
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150812111555
137618230663
142823483521
115118954432
113804366339
69077246382
70682117613
05876977367
2080268363
ED
4
5
6
7
8
9
ES
-05876977367
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63145903326
6277116534
50575716091
470634351
43881048239
3794853304
45690667275
34906659277
129884842743
125922322732
126094054781
125636410314
105752371459
110940331947
120254632691
99721457036
191263214987
187718399817
192328453309
203354827871
168821684706
19423632711
201535401914
171178669966
243101540178
241914273209
234329184933
259628676125
222814160851
263685913142
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131111960188
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103592077393
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ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
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592609055078
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
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63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
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75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
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221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
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08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
x-ft x-ft
-2212921873 -2044349067
-237626439 -2179641184
-2154410172 -2019974617
-1474464567 -1437960459
-4164729804 -451461207
7565474164 6951134457
1696001042 1625839052
2147746939 2055635702
2087413663 1964478499
1706936177 1578059694
1263924629 1174279981
9127607086 8825441865
6410534119 6372581287
3378275489 2987247802
-0870639766 -1918366841
-6350843845 -7654582209
-1235249446 -1304154016
-1793740377 -1736944457
x-ft y-ft z-ft x-ft y-ft z-ft
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
78971395061 130321103309 1007977901068 93553704809 135233393779 898194735069 -78971395061 -130321103309 -93553704809 -135233393779
124335968095 113875343787 1015784038439 144990276975 123005410379 911533231381 -124335968095 -113875343787 -144990276975 -123005410379
160906165418 83838326776 1007381376667 177243362817 95935148128 91524687888 -160906165418 -83838326776 -177243362817 -95935148128
190289540028 27344482344 989856046861 189800830761 42608371525 914502141473 -190289540028 -27344482344 -189800830761 -42608371525
206815591073 -57090978689 977186870169 184509550333 -39998621875 918069689921 -206815591073 57090978689 -184509550333 39998621875
196459813393 -153124889252 977553515199 160745277178 -13811966148 927886773251 -196459813393 153124889252 -160745277178 13811966148
146495267958 -233871439232 986889629267 115397905403 -224479093749 935655467687 -146495267958 233871439232 -115397905403 224479093749
58652508711 -277122500416 994361396641 48396760253 -272257489961 930429787136 -58652508711 277122500416 -48396760253 272257489961
-46324177435 -276245542685 993670631365 -31654055086 -269611895562 909937127266 46324177435 276245542685 31654055086 269611895562
-138258220816 -239213835387 98868763227 -108077305473 -22410848541 884270927189 138258220816 239213835387 108077305473 22410848541
-194461227149 -179146271838 988106267463 -163773510776 -154968035054 867849318539 194461227149 179146271838 163773510776 154968035054
-210652032096 -106291601476 995154626023 -190005793829 -80711897756 867060320248 210652032096 106291601476 190005793829 80711897756
-197974753618 -27822404151 1003379939044 -189079640356 -12007277087 875368531514 197974753618 27822404151 189079640356 12007277087
-170438339716 47468943594 1003155821306 -169150760352 46978640854 880465165201 170438339716 -47468943594 169150760352 -46978640854
-134636022002 107514814377 992335030466 -136443799202 93529361012 876358495915 134636022002 -107514814377 136443799202 -93529361012
-89747799628 14226875881 979875440936 -92033256614 124499793527 868674335351 89747799628 -14226875881 92033256614 -124499793527
-35128961091 151043227866 978072397327 -35410190772 138987834304 868319106901 35128961091 -151043227866 35410190772 -138987834304
24022164913 14333781419 990571741698 29677353199 140727587992 880176899249 -24022164913 -14333781419 -29677353199 -140727587992
-24022164913 -29677353199
-78971395061 -93553704809
-124335968095 -144990276975
-160906165418 -177243362817
-190289540028 -189800830761
-206815591073 -184509550333
-196459813393 -160745277178
-146495267958 -115397905403
-58652508711 -48396760253
46324177435 31654055086
138258220816 108077305473
194461227149 163773510776
210652032096 190005793829
197974753618 189079640356
170438339716 169150760352
134636022002 136443799202
89747799628 92033256614
35128961091 35410190772
-24022164913 -29677353199
Page 16: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart2

-14333781419
-140727587992
-130321103309
-135233393779
-113875343787
-123005410379
-83838326776
-95935148128
-27344482344
-42608371525
57090978689
39998621875
153124889252
13811966148
233871439232
224479093749
277122500416
272257489961
276245542685
269611895562
239213835387
22410848541
179146271838
154968035054
106291601476
80711897756
27822404151
12007277087
-47468943594
-46978640854
-107514814377
-93529361012
-14226875881
-124499793527
-151043227866
-138987834304
-14333781419
-140727587992

Sheet1

Sheet1

ED
ES
0
0
-05876977367
-03229358468
63145903326
6277116534
129884842743
125922322732
191263214987
187718399817
243101540178
241914273209
274022641715
271682601998
268305801613
259689876921
217568277546
202879605084
131111960188
117978567573
34228417088
31627463314
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Sheet2

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05876977367
2080268363
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4
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8
9
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191263214987
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203354827871
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171178669966
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4
5
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7
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X-Z plane
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825114311281
787747668089
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
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126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
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ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
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134636022002 136443799202
89747799628 92033256614
35128961091 35410190772
-24022164913 -29677353199
Page 17: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart2

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Sheet1

Sheet1

ED
ES
0
0
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63145903326
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Sheet2

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4
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9
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125922322732
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191263214987
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X-Z plane
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2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
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Page 18: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

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131111960188
117978567573
96536503502
95975425563
103592077393
87491815597
9239266766
100857749979
34228417088
31627463314
23960394594
16640883112
16447911216
12614751883
15733108747
2100375707
-45981099105
-3676826918
-45021331702
-46390321178
-52625173518
-35708999614
-3980953506
-3949446103
-9617816235
-84616210167
-103435925205
-90331233421
-94552135835
-66640710409
-79770111414
-81673733266
-121026326459
-120571150061
-145454133355
-117750304909
-114127045934
-93165576259
-111984546229
-113662349613
-133438907215
-150479111794
-167457183401
-13159308096
-1214265091
-117696659253
-136186151287
-138575327137
-140486256835
-168877088223
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-133221681678
-122175329849
-131416930682
-144952488224
-150812111555
-137618230663
-163751723919
-153518020128
-123139169233
-114765017599
-125351248578
-132852560031
-142823483521
-115118954432
-128833149291
-123117457791
-101588340924
-94557051383
-99882297897
-102685071866
-113804366339
-69077246382
-70604704586
-78910900631
-67657371798
-59630190633
-62608453497
-61906149326
-70682117613
-05876977367
-03229358468
-20394345834
-18727874802
-12254164167
-18043997938
-13801236595
-2080268363
ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
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627851394652
1042713199654
984433244397
930995131001
904037456604
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71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
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1014636795116
965698558024
853215860433
855067565764
823876662623
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701166085256
739999879474
935727207541
894157990252
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706388901446
685648742129
637831121746
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617456648824
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751905041551
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591358715289
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549269837143
772712028134
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730552468751
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607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
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783327934105
737682445175
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639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
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708642756102
644947216204
614648003084
551182202124
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847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
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627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
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625494204408
591358715289
594186664958
549269837143
772712028134
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584336598146
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518227284972
804326532071
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763430356667
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651983621581
623936064908
561041223015
606017884293
885949323766
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80116345201
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677689404639
648426104829
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889104522167
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671597868957
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913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
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Page 19: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

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609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
221292187321 167269869521
237626439025 161879392695
215441017187 147573974009
147446456713 1102219069
41647298038 38278786183
-75654741645 -57309481748
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-64105341193 -70759153016
-33782754889 -41868440645
08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
x-ft x-ft
-2212921873 -2044349067
-237626439 -2179641184
-2154410172 -2019974617
-1474464567 -1437960459
-4164729804 -451461207
7565474164 6951134457
1696001042 1625839052
2147746939 2055635702
2087413663 1964478499
1706936177 1578059694
1263924629 1174279981
9127607086 8825441865
6410534119 6372581287
3378275489 2987247802
-0870639766 -1918366841
-6350843845 -7654582209
-1235249446 -1304154016
-1793740377 -1736944457
Page 20: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Sheet2

Sheet3

05876977367
2080268363
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05876977367
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ED
4
5
6
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8
9
ES
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191263214987
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171178669966
243101540178
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ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
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4
5
6
7
8
9
ES
Y-Z plane
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634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
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131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
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75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
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170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
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75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
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ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
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-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
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33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
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221292187321 167269869521
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41647298038 38278786183
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08706397655 14393103806
63508438445 82601295229
12352494464 13684141889
179374037705 163110928029
221292187321 167269869521
Page 21: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Sheet3

05876977367
2080268363
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ED
4
5
6
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8
9
ES
-05876977367
-03229358468
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63145903326
6277116534
50575716091
470634351
43881048239
3794853304
45690667275
34906659277
129884842743
125922322732
126094054781
125636410314
105752371459
110940331947
120254632691
99721457036
191263214987
187718399817
192328453309
203354827871
168821684706
19423632711
201535401914
171178669966
243101540178
241914273209
234329184933
259628676125
222814160851
263685913142
266307765481
233925693679
274022641715
271682601998
242555584319
275966170956
251606560343
289454293134
288165866473
264659148883
268305801613
259689876921
216653864225
245988012703
240468620862
256928889391
255552951404
247175082556
217568277546
202879605084
164267994531
179246558452
186506126669
17887323146
180866058419
185111488732
131111960188
117978567573
96536503502
95975425563
103592077393
87491815597
9239266766
100857749979
34228417088
31627463314
23960394594
16640883112
16447911216
12614751883
15733108747
2100375707
-45981099105
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-03229358468
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-18727874802
-12254164167
-18043997938
-13801236595
-2080268363
ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
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596452125313
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703050688784
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561041223015
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913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
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689030985016
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1022547500133
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787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
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ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
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221292187321 167269869521
Page 22: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
ED
4
5
6
7
8
9
ES
-05876977367
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ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
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ED
4
5
6
7
8
9
ES
Y-Z plane
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599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
ED 4 5 6 7 8 9 ES
x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft z-ft x-ft y-ft x-ft y-ft x-ft y-ft x-ft y-ft
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
-237626439025 63145903326 1001229079308 -217964118388 6277116534 92461296484 -198790948094 50575716091 849265913122 -20198899141 470634351 824495450328 -189357236555 43881048239 721247407131 -199067164213 3794853304 679337594802 -192434280805 45690667275 6556650159 -161879392695 34906659277 587657818332 -237626439025 63145903326 -161879392695 34906659277 237626439025 -63145903326 161879392695 -34906659277
-215441017187 129884842743 1009712978745 -201997461695 125922322732 934207315996 -178845900561 126094054781 885704581939 -188535090983 125636410314 856952728773 -173705756088 105752371459 723983988846 -177379829818 110940331947 689030985016 -184155629774 120254632691 677492319663 -147573974009 99721457036 592609055078 -215441017187 129884842743 -147573974009 99721457036 215441017187 -129884842743 147573974009 -99721457036
-147446456713 191263214987 1022547500133 -143796045852 187718399817 955758990034 -12556834074 192328453309 920090103091 -132509413824 203354827871 885598657653 -118179091611 168821684706 750091691934 -119965489267 19423632711 722795465944 -132696172241 201535401914 700577658262 -1102219069 171178669966 627851394652 -147446456713 191263214987 -1102219069 171178669966 147446456713 -191263214987 1102219069 -171178669966
-41647298038 243101540178 1042713199654 -45146120697 241914273209 984433244397 -42558050142 234329184933 930995131001 -39664091472 259628676125 904037456604 -30272318103 222814160851 796114099718 -32156589805 263685913142 768846893875 -40720900095 266307765481 71854482512 -38278786183 233925693679 685067477275 -41647298038 243101540178 -38278786183 233925693679 41647298038 -243101540178 38278786183 -233925693679
75654741645 274022641715 1049083020787 6951134457 271682601998 995796772194 50343083728 242555584319 906197006122 62401115202 275966170956 897653059855 65089934794 251606560343 831835885924 63730723355 289454293134 794888746191 63911590584 288165866473 720770574774 57309481748 264659148883 733548399171 75654741645 274022641715 57309481748 264659148883 -75654741645 -274022641715 -57309481748 -264659148883
169600104246 268305801613 1014636795116 16258390522 259689876921 965698558024 126232004773 216653864225 853215860433 139157850761 245988012703 855067565764 138564400926 240468620862 823876662623 137161119353 256928889391 774427626731 143370906757 255552951404 701166085256 14271742887 247175082556 739999879474 169600104246 268305801613 14271742887 247175082556 -169600104246 -268305801613 -14271742887 -247175082556
214774693926 217568277546 935727207541 20556357019 202879605084 894157990252 167310777314 164267994531 794626661117 171074329962 179246558452 782587622367 173442276856 186506126669 765657163701 167245946559 17887323146 711071748631 174786893975 180866058419 664628600302 183982330079 185111488732 694009419853 214774693926 217568277546 183982330079 185111488732 -214774693926 -217568277546 -183982330079 -185111488732
208741366314 131111960188 842974940949 196447849906 117978567573 81024849353 17446604126 96536503502 752141466352 164227162736 95975425563 706388901446 173198548286 103592077393 685648742129 15561260229 87491815597 637831121746 163780736302 9239266766 624716088582 173172742737 100857749979 617456648824 208741366314 131111960188 173172742737 100857749979 -208741366314 -131111960188 -173172742737 -100857749979
170693617732 34228417088 780782176574 15780596938 31627463314 751905041551 162240464133 23960394594 733177744334 141008017707 16640883112 65730439202 1541751108 16447911216 625494204408 123162269091 12614751883 591358715289 135366550542 15733108747 594186664958 133498355845 2100375707 549269837143 170693617732 34228417088 133498355845 2100375707 -170693617732 -34228417088 -133498355845 -2100375707
126392462901 -45981099105 772712028134 117427998059 -3676826918 738018121864 144293955289 -45021331702 730552468751 119967377716 -46390321178 649588927288 130811102495 -52625173518 607678404055 93118920065 -35708999614 584336598146 111278056404 -3980953506 576748843136 9803061908 -3949446103 518227284972 126392462901 -45981099105 9803061908 -3949446103 -126392462901 45981099105 -9803061908 3949446103
9127607086 -9617816235 804326532071 88254418653 -84616210167 757412602408 122666590233 -103435925205 733401664916 102758759366 -90331233421 671807365975 106356296339 -94552135835 621762110772 74472758535 -66640710409 600366101814 94225494682 -79770111414 56715160314 81477679599 -81673733266 526222424581 9127607086 -9617816235 81477679599 -81673733266 -9127607086 9617816235 -81477679599 81673733266
64105341193 -121026326459 839058161139 6372581287 -120571150061 783327934105 89779213959 -145454133355 737682445175 7826889018 -117750304909 697897150631 75580482999 -114127045934 639940068583 58971422471 -93165576259 61392241189 716772621 -111984546229 558802335519 70759153016 -113662349613 553863783053 64105341193 -121026326459 70759153016 -113662349613 -64105341193 121026326459 -70759153016 113662349613
33782754889 -133438907215 851669934889 29872478023 -150479111794 79838876797 39690775242 -167457183401 746729792554 37493941612 -13159308096 708642756102 34397511289 -1214265091 644947216204 32335704579 -117696659253 614648003084 32770492091 -136186151287 551182202124 41868440645 -138575327137 580044847991 33782754889 -133438907215 41868440645 -138575327137 -33782754889 133438907215 -41868440645 138575327137
-08706397655 -140486256835 847952298041 -19183668413 -168877088223 806564474405 -23161336506 -169261460108 763430356667 -1633063925 -133221681678 705004733831 -14130623025 -122175329849 643121786473 -11741889872 -131416930682 612952033077 -19467532498 -144952488224 550073042004 -14393103806 -150812111555 596452125313 -08706397655 -140486256835 -14393103806 -150812111555 08706397655 140486256835 14393103806 150812111555
-63508438445 -137618230663 853684513389 -76545822087 -163751723919 822863426826 -8593438312 -153518020128 784052886909 -7124893002 -123139169233 703050688784 -62574975635 -114765017599 651983621581 -66968415689 -125351248578 623936064908 -71722471037 -132852560031 561041223015 -82601295229 -142823483521 606017884293 -63508438445 -137618230663 -82601295229 -142823483521 63508438445 137618230663 82601295229 142823483521
-12352494464 -115118954432 885949323766 -130415401619 -128833149291 853722899411 -136967575418 -123117457791 80116345201 -117947751342 -101588340924 717314515126 -105938731553 -94557051383 677689404639 -120973080666 -99882297897 648426104829 -113853583951 -102685071866 583230513319 -13684141889 -113804366339 611659796933 -12352494464 -115118954432 -13684141889 -113804366339 12352494464 115118954432 13684141889 113804366339
-179374037705 -69077246382 935951484467 -17369444572 -70604704586 889104522167 -172489770936 -78910900631 812458521258 -155586914473 -67657371798 748860512376 -143726221478 -59630190633 706981187386 -164190917954 -62608453497 671597868957 -146468395696 -61906149326 609796666213 -163110928029 -70682117613 610377712513 -179374037705 -69077246382 -163110928029 -70682117613 179374037705 69077246382 163110928029 70682117613
-221292187321 -05876977367 979290747947 -204434906738 -03229358468 913779502576 -193769653438 -20394345834 825114311281 -185741138967 -18727874802 787747668089 -174482821967 -12254164167 72194700833 -191856663356 -18043997938 680226372768 -174169018099 -13801236595 634225640215 -167269869521 -2080268363 599663941193 -221292187321 -05876977367 -167269869521 -2080268363 221292187321 05876977367 167269869521 2080268363
Page 23: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
ED
4
5
6
7
8
9
ES
-05876977367
-03229358468
-20394345834
-18727874802
-12254164167
-18043997938
-13801236595
-2080268363
63145903326
6277116534
50575716091
470634351
43881048239
3794853304
45690667275
34906659277
129884842743
125922322732
126094054781
125636410314
105752371459
110940331947
120254632691
99721457036
191263214987
187718399817
192328453309
203354827871
168821684706
19423632711
201535401914
171178669966
243101540178
241914273209
234329184933
259628676125
222814160851
263685913142
266307765481
233925693679
274022641715
271682601998
242555584319
275966170956
251606560343
289454293134
288165866473
264659148883
268305801613
259689876921
216653864225
245988012703
240468620862
256928889391
255552951404
247175082556
217568277546
202879605084
164267994531
179246558452
186506126669
17887323146
180866058419
185111488732
131111960188
117978567573
96536503502
95975425563
103592077393
87491815597
9239266766
100857749979
34228417088
31627463314
23960394594
16640883112
16447911216
12614751883
15733108747
2100375707
-45981099105
-3676826918
-45021331702
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-3949446103
-9617816235
-84616210167
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-79770111414
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-114127045934
-93165576259
-111984546229
-113662349613
-133438907215
-150479111794
-167457183401
-13159308096
-1214265091
-117696659253
-136186151287
-138575327137
-140486256835
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-150812111555
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-153518020128
-123139169233
-114765017599
-125351248578
-132852560031
-142823483521
-115118954432
-128833149291
-123117457791
-101588340924
-94557051383
-99882297897
-102685071866
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-70604704586
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-18727874802
-12254164167
-18043997938
-13801236595
-2080268363
ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
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685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
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706388901446
685648742129
637831121746
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549269837143
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730552468751
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607678404055
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518227284972
804326532071
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671807365975
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600366101814
56715160314
526222424581
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551182202124
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763430356667
705004733831
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612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
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889104522167
812458521258
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706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
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765657163701
711071748631
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694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
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607678404055
584336598146
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518227284972
804326532071
757412602408
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671807365975
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600366101814
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526222424581
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703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
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677689404639
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671597868957
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979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
Page 24: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
ED
4
5
6
7
8
9
ES
X-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
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627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
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71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
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694009419853
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81024849353
752141466352
706388901446
685648742129
637831121746
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549269837143
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730552468751
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607678404055
584336598146
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518227284972
804326532071
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671807365975
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600366101814
56715160314
526222424581
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737682445175
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558802335519
553863783053
851669934889
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746729792554
708642756102
644947216204
614648003084
551182202124
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847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
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856952728773
723983988846
689030985016
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1022547500133
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1042713199654
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796114099718
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71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
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823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
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765657163701
711071748631
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81024849353
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706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
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625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
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607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
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600366101814
56715160314
526222424581
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847952298041
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763430356667
705004733831
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612952033077
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703050688784
651983621581
623936064908
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606017884293
885949323766
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80116345201
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979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
-237626439025 -217964118388 -198790948094 -20198899141 -189357236555 -199067164213 -192434280805 -161879392695
-215441017187 -201997461695 -178845900561 -188535090983 -173705756088 -177379829818 -184155629774 -147573974009
-147446456713 -143796045852 -12556834074 -132509413824 -118179091611 -119965489267 -132696172241 -1102219069
-41647298038 -45146120697 -42558050142 -39664091472 -30272318103 -32156589805 -40720900095 -38278786183
75654741645 6951134457 50343083728 62401115202 65089934794 63730723355 63911590584 57309481748
169600104246 16258390522 126232004773 139157850761 138564400926 137161119353 143370906757 14271742887
214774693926 20556357019 167310777314 171074329962 173442276856 167245946559 174786893975 183982330079
208741366314 196447849906 17446604126 164227162736 173198548286 15561260229 163780736302 173172742737
170693617732 15780596938 162240464133 141008017707 1541751108 123162269091 135366550542 133498355845
126392462901 117427998059 144293955289 119967377716 130811102495 93118920065 111278056404 9803061908
9127607086 88254418653 122666590233 102758759366 106356296339 74472758535 94225494682 81477679599
64105341193 6372581287 89779213959 7826889018 75580482999 58971422471 716772621 70759153016
33782754889 29872478023 39690775242 37493941612 34397511289 32335704579 32770492091 41868440645
-08706397655 -19183668413 -23161336506 -1633063925 -14130623025 -11741889872 -19467532498 -14393103806
-63508438445 -76545822087 -8593438312 -7124893002 -62574975635 -66968415689 -71722471037 -82601295229
-12352494464 -130415401619 -136967575418 -117947751342 -105938731553 -120973080666 -113853583951 -13684141889
-179374037705 -17369444572 -172489770936 -155586914473 -143726221478 -164190917954 -146468395696 -163110928029
-221292187321 -204434906738 -193769653438 -185741138967 -174482821967 -191856663356 -174169018099 -167269869521
Page 25: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of
ED
4
5
6
7
8
9
ES
Y-Z plane
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193
1001229079308
92461296484
849265913122
824495450328
721247407131
679337594802
6556650159
587657818332
1009712978745
934207315996
885704581939
856952728773
723983988846
689030985016
677492319663
592609055078
1022547500133
955758990034
920090103091
885598657653
750091691934
722795465944
700577658262
627851394652
1042713199654
984433244397
930995131001
904037456604
796114099718
768846893875
71854482512
685067477275
1049083020787
995796772194
906197006122
897653059855
831835885924
794888746191
720770574774
733548399171
1014636795116
965698558024
853215860433
855067565764
823876662623
774427626731
701166085256
739999879474
935727207541
894157990252
794626661117
782587622367
765657163701
711071748631
664628600302
694009419853
842974940949
81024849353
752141466352
706388901446
685648742129
637831121746
624716088582
617456648824
780782176574
751905041551
733177744334
65730439202
625494204408
591358715289
594186664958
549269837143
772712028134
738018121864
730552468751
649588927288
607678404055
584336598146
576748843136
518227284972
804326532071
757412602408
733401664916
671807365975
621762110772
600366101814
56715160314
526222424581
839058161139
783327934105
737682445175
697897150631
639940068583
61392241189
558802335519
553863783053
851669934889
79838876797
746729792554
708642756102
644947216204
614648003084
551182202124
580044847991
847952298041
806564474405
763430356667
705004733831
643121786473
612952033077
550073042004
596452125313
853684513389
822863426826
784052886909
703050688784
651983621581
623936064908
561041223015
606017884293
885949323766
853722899411
80116345201
717314515126
677689404639
648426104829
583230513319
611659796933
935951484467
889104522167
812458521258
748860512376
706981187386
671597868957
609796666213
610377712513
979290747947
913779502576
825114311281
787747668089
72194700833
680226372768
634225640215
599663941193

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
63145903326 6277116534 50575716091 470634351 43881048239 3794853304 45690667275 34906659277
129884842743 125922322732 126094054781 125636410314 105752371459 110940331947 120254632691 99721457036
191263214987 187718399817 192328453309 203354827871 168821684706 19423632711 201535401914 171178669966
243101540178 241914273209 234329184933 259628676125 222814160851 263685913142 266307765481 233925693679
274022641715 271682601998 242555584319 275966170956 251606560343 289454293134 288165866473 264659148883
268305801613 259689876921 216653864225 245988012703 240468620862 256928889391 255552951404 247175082556
217568277546 202879605084 164267994531 179246558452 186506126669 17887323146 180866058419 185111488732
131111960188 117978567573 96536503502 95975425563 103592077393 87491815597 9239266766 100857749979
34228417088 31627463314 23960394594 16640883112 16447911216 12614751883 15733108747 2100375707
-45981099105 -3676826918 -45021331702 -46390321178 -52625173518 -35708999614 -3980953506 -3949446103
-9617816235 -84616210167 -103435925205 -90331233421 -94552135835 -66640710409 -79770111414 -81673733266
-121026326459 -120571150061 -145454133355 -117750304909 -114127045934 -93165576259 -111984546229 -113662349613
-133438907215 -150479111794 -167457183401 -13159308096 -1214265091 -117696659253 -136186151287 -138575327137
-140486256835 -168877088223 -169261460108 -133221681678 -122175329849 -131416930682 -144952488224 -150812111555
-137618230663 -163751723919 -153518020128 -123139169233 -114765017599 -125351248578 -132852560031 -142823483521
-115118954432 -128833149291 -123117457791 -101588340924 -94557051383 -99882297897 -102685071866 -113804366339
-69077246382 -70604704586 -78910900631 -67657371798 -59630190633 -62608453497 -61906149326 -70682117613
-05876977367 -03229358468 -20394345834 -18727874802 -12254164167 -18043997938 -13801236595 -2080268363
Page 26: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 27: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 28: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

2017 -FTR is ignored STS Database

MR + TR

Annual New MR

Annual MR Surgeries

Annual TR Surgeries

MR - 4000000TR - 1600000

250000

60000

8000

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 29: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Tricuspid repair when fixing MR Based on TR Grade

1 39

39

79

0

20

40

60

80

100

Percent of Patients Having Tricuspid Repair

Preoperative TR Grade

None Mild Moderate Severe

Source STS Database N = 46500V 273 2011-2013

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 30: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Functional TR ndash dynamic under anesthesia 4+ TR can become mildhellip

Regard any previous significant TR or a dilated annulus as indications for TV repair

0

05

1

15

2

25

3

35

Pre-Operative Pre-Bypass Post-Bypass

Mea

n TR

Gra

de

When to look for FTR Pre-op

Frater (JTCVS 1222001)

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 31: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

If in OR donrsquot just look for TR Look for annulus gt 40 mm

RA RV changes

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 32: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)

Preop 16 had severe 34+ TRhellip

Discharge (MVR without TVr)

62 had residual severe TR hellip

TR does not

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 33: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

No guarantee of FTR ldquogetting betterrdquo

and despite a ldquogoodrdquo mitral resulthellip

King 1984 66 FTR 14 months

Saafie 1985 35 FTR post MVr

Sagie 1994 62 FTR post MVr

Porter 1999 67 FTR 11 yrs

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 34: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Dreyfus Annals of Thoracic Surgery 2005

Tricuspid Valve Repair

311 Patients MV Repair

Preop TR 07 ndash 09

93 notracemild

7 moderate

NONE Severe

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 35: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

TR Does Not Just ldquoGo Awayrdquo After MVr311 undergoing MVr mostly degenerative all with dilated TV annulus

Dreyfus Ann Thorac Surg 200579127

0

10

20

30

40

50

60

TR Worsening by gt 2 Grades

MVR only

48

MVR+TVR2

Plt0001

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 36: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Adding TV repair adds risk

Ann Thorac Surg 2009 Mar87(3)698-703Mitral valve surgery for functional mitral regurgitation should moderate-or-more tricuspid regurgitation be treated a propensity score analysisCalafiore AM

110 matched pts for MVr with FTR85 - 30 day mortality no TVr vs 2 - for MVr + TVr p= 02

TR progression rate was 40 vs 55-yr survival was 45 vs 74

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 37: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Adding TV repair adds risk

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 38: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR - Donrsquot Wait Bernal (JTCVS 1302005)

Patients left with post-op FTR when returned for redo TVr

30 day mortality was 35 Highest op mortality in STS

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 39: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

How to fix FTR New Repair Thinking for Functional TR

Annuloplasty Rings DeVega

DeVega Rev Esp Cardiol 1972256

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 40: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Use a Ring Less recurrent TR and better Survival

702 patients - TVR493 DeVega209 Ring

Tang Circulation 2006114I-577

FreedomFrom

RecurrentTR ()

FreedomFromDeath()

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 41: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

DavidJTCVS2009

Navia JTCVS 2010

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 42: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

2o FTR - Use a rigid ring Carrier JHVD 132004

463 patients for TV repairs Freedom from recurrence

Rigid ring - 94Flexible - 72DeVega - 66

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 43: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

TV ring risks fears

AV Node injuryDehiscenceHemolysis

Endocarditis

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 44: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

ldquoClassicrdquo Tricuspid Technique

helliptime to injure the AV node

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 45: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

New ldquoHow tordquo Anatomy of FTR

Annular RA RV and LV geometry changes of TRCarpentier JTCVS 19746753

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 46: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

New FTR - ldquoRule of TENrdquo

Triangle of Koch

Taramasso JACC 2012

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 47: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR repair - ldquo10rdquoldquoTen stitches - Ten minutesrdquo

ldquo10 orsquoclock to 6 orsquoclockrdquo

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 48: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR - 10 stitches 10 orsquoclock to 6 orsquoclock

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 49: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

How to size FTRhellipDonrsquot size

26 28 RING

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 50: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Pathophysiology of Functional Secondary TRWhat size

NORMAL TRICUSPID ANNULAR DIMENSION

28 + 05 cm Sugimoto T J Thorac Cardiovasc Surg 1999117463-71

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 51: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

ldquoUndersizedrdquo TV repair for FTR

Actually RE-NORMAL size

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 52: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

TR Grade

Preoperative

Predischarge

Follow-up (mean = 1 yr)

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

None Mild Moderate Mod-to-Severe Severe

ldquoUndersizedrdquo TV repair for FTR

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 53: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
0
0
29
27
44

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Preoperative Preoperative Preoperative Preoperative Preoperative
Page 54: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Sheet1

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Preoperative 0 0 29 27 44 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Page 55: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Chart1

None
Mild
Moderate
Moderate-to-Severe
Severe
57
30
10
1
2

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Follow-up Follow-up Follow-up Follow-up Follow-up
Page 56: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Sheet1

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
None Mild Moderate Moderate-to-Severe Severe Intraoperative After Repair 94 6 0 0 0
Follow-up 57 30 10 1 2 Predischarge 72 21 4 3 0
Follow-up 52 35 10 1 2
To resize chart data range drag lower right corner of range
Page 57: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Will I get Stenosis NO - Πr226 mm = 4 cm2

2-3 mm gradient

The tricuspid valve current perspective andevolving management of tricuspid regurgitation

Rogers JH Bolling SF Circulation 2009 May 26119(20)2718-25

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 58: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

180160140120100

80604020

0

RVE

DV

What about RV failure

RVE

SV

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 59: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

70

60

50

40

30

20

10

0

RVE

F

The RV gets better

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 60: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Tricuspid Annuloplasty Concomitant with Left-Sided Cardiac Surgery Effects on Right Ventricular Remodeling

Philippe B Bertrand MD MScab Gille Koppers MScb Frederik H Verbrugge MDab Wilfried Mullens MD PhDab Rozette Reyskens RNa Herbert Gutermann MDa Chris Van Kerrebroeck MD PhDa Robert Dion MD PhDa Pieter Vandervoort MDab David Verhaert MDa

a Department of Cardiovascular Medicine Hospital Oost-Limburg Genk Belgiumb School of Medicine and Life Sciences Hasselt University Hasselt Belgium J Thorac Cardiovasc Surg In press

When FTR is fixed the RV gets better

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 61: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR

Lack of reop is not the same as a good outcome

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 62: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality

Nath JACC 200443405

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 63: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Fix TR hellip if you are there Current Guidelines for TV Surgery

2014 ACCAHAbull Class I

bull Severe TR in a patient undergoing left sided valve surgery

bull Class IIabull TV repair is beneficial for

gt Mild TR when there is tricuspid annular dilatation or right HF

bull Class IIbbull TV repair considered for

FTR in presence of PH or RV dilationdysfunction

2012 ESCEACTSbull Class I

bull Severe TR in a patient undergoing left-sided valve surgery

bull Class IIa

bull Moderate 2nd TR with dilated tricuspid annulus (gt40 mm) in a patient undergoing left-sided valve surgery or with RV dilationdysfunction

Data

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 64: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Far less TR better RVNO mortality or PPM

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 65: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Outcomes of Guideline directed Repairof FTR performed during MV surgery

Ward Romano Bolling AATS 2017

262 pts TVr modsev or lt moderate TR262830 ring

No mortality No TS RV improved

1 progression to severe TR- 26 de novo PPM rate

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 66: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

CTSNet TR Trial - 137400 pts

bull DMR repairbull Mod TR or mild TR with annular dilation gt 40bull Randomized plusmnTV annuloplasty

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 67: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Percutaneous data for TR

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 68: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR Surgery Percutaneous Implications

TV PercRings

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 69: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR Percutaneous ldquoNotrdquo Rings

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 70: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Tricuspid Regurgitation4-TECH

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 71: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

Tricuspid RegurgitationMitralignhellip Trialign

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 72: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR Percutaneous ldquoother thingsrdquo

More dataneededhellip

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 73: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR Data NOW TR not importanthellip NOLook for TR in ORhellip NONot much TR aroundhellip NORepair Mitral TR goes away hellip NOAdds operative mortality to do a TVrhellip NODonrsquot know how tohellip NORV will failhellip NOWill get TShellip NOWonrsquot make long-term differencehellip NOGuidelines are vaguehellip NO

FTR Donrsquot wait for more datahellip

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it
Page 74: Concomitant Tricuspid Valve Repair : When to perform…while ... · Concomitant Tricuspid Valve Repair : When to perform…while awaiting data?! Steven F Bolling, MD Professor of

FTR Put a ring on it

  • Concomitant Tricuspid Valve Repair When to performhellipwhile awaiting data
  • Is FTR important
  • hellipand FTR patients die FTR increases Mortality
  • Severe and MODERATE FTR Decreases Survival
  • Annular Dilation Shape Change of FTR 75- all cases of MR
  • Slide Number 6
  • Slide Number 7
  • When to look for FTR Pre-op Frater (JTCVS 1222001)
  • Slide Number 9
  • FTR goes away by itself 5589 MVr only cases (McCarthy ATS 2004)
  • Slide Number 11
  • Slide Number 12
  • TR Does Not Just ldquoGo Awayrdquo After MVr
  • Adding TV repair adds risk
  • Adding TV repair adds risk
  • FTR - Donrsquot Wait Bernal (JTCVS 1302005)
  • How to fix FTR New Repair Thinking for Functional TR
  • Use a Ring Less recurrent TR and better Survival
  • Slide Number 19
  • 2o FTR - Use a rigid ring Carrier JHVD 132004
  • TV ring risks fears
  • ldquoClassicrdquo Tricuspid Technique
  • New ldquoHow tordquo Anatomy of FTR
  • New FTR - ldquoRule of TENrdquo
  • FTR repair - ldquo10rdquo
  • FTR - 10 stitches 10 orsquoclock to 6 orsquoclock
  • How to size FTRhellipDonrsquot size
  • Slide Number 28
  • Slide Number 29
  • Slide Number 30
  • Will I get Stenosis NO - Pr2
  • Slide Number 32
  • Slide Number 33
  • Slide Number 34
  • Residual Tricuspid Insufficiency DONrsquoT LEAVE MOD TR
  • ldquo I donrsquot see these patients come backrdquohellipMod TR Increases Mortality
  • Fix TR hellip if you are there Current Guidelines for TV Surgery
  • Slide Number 39
  • Outcomes of Guideline directed Repair of FTR performed during MV surgery
  • CTSNet TR Trial - 137400 pts
  • Slide Number 42
  • FTR Surgery Percutaneous Implications
  • FTR Percutaneous ldquoNotrdquo Rings
  • Tricuspid Regurgitation4-TECH
  • Tricuspid RegurgitationMitralignhellip Trialign
  • FTR Percutaneous ldquoother thingsrdquo
  • FTR Data NOW
  • FTR Put a ring on it

TRICUSPID ATRESIA

TRICUSPID ATRESIA

Documents
Asymptomatic Isolate Tricuspid Regurgitation with Chordae

Asymptomatic Isolate Tricuspid Regurgitation with Chordae

Documents
Eae Recommendations Mitral Tricuspid Regurgitation.full

Eae Recommendations Mitral Tricuspid Regurgitation.full

Documents
Tricuspid regurgitation and echocardiography

Tricuspid regurgitation and echocardiography

Education
CONCOMITANT INGUINAL ENDOMETRIOSIS AND GROIN …umbalk.org/.../2017/12/16.CONCOMITANT-INGUINAL-ENDOMETRIOSIS-AND-GRO… · CONCOMITANT INGUINAL ENDOMETRIOSIS AND GROIN HERNIA

CONCOMITANT INGUINAL ENDOMETRIOSIS AND GROIN …umbalk.org/.../2017/12/16.CONCOMITANT-INGUINAL-ENDOMETRIOSIS-AND-GRO… · CONCOMITANT INGUINAL ENDOMETRIOSIS AND GROIN HERNIA

Documents
Tricuspid and Pulmonic Valve Disease - Dr. Stultz 01 13 Tricuspid and Pulmonic... · Tricuspid andTricuspid and PulmonicPulmonic Valve DiseaseValve Disease The Forgotten ValvesThe

Tricuspid and Pulmonic Valve Disease - Dr. Stultz 01 13 Tricuspid and Pulmonic... · Tricuspid andTricuspid and PulmonicPulmonic Valve DiseaseValve Disease The Forgotten ValvesThe

Documents
concomitant strabismus

concomitant strabismus

Health & Medicine
Know about tricuspid valve regurgitation

Know about tricuspid valve regurgitation

Healthcare
CONCOMITANT SYMPTOMS & REMEDIEShomoeopathybooks.com/Repertory of Concomitant Symptoms-1/Repe… · CONCOMITANT SYMPTOMS & REMEDIES :- GRAPH., KALI FACE :[ABDOMEN] : ... aconite if

CONCOMITANT SYMPTOMS & REMEDIEShomoeopathybooks.com/Repertory of Concomitant Symptoms-1/Repe… · CONCOMITANT SYMPTOMS & REMEDIES :- GRAPH., KALI FACE :[ABDOMEN] : ... aconite if

Documents
#5 Tricuspid and Mitral Inflow Doppler

#5 Tricuspid and Mitral Inflow Doppler

Documents
Unusual Tricuspid Valve Regurgitation

Unusual Tricuspid Valve Regurgitation

Health & Medicine
Concomitant Tricuspid Valve Repair : When, Why and How · PDF fileConcomitant Tricuspid Valve Repair : When, Why and How ! ... TR Does Not Just “Go Away” After MVr ... Adding TV

Concomitant Tricuspid Valve Repair : When, Why and How · PDF fileConcomitant Tricuspid Valve Repair : When, Why and How ! ... TR Does Not Just “Go Away” After MVr ... Adding TV

Documents
Tricuspid Valve Disease

Tricuspid Valve Disease

Documents
Tricuspid Atresia - chfed.org.uk · Tricuspid Atresia The aim of this information sheet is to explain what Tricuspid Atresia is, what effect it will have on a child and how it can

Tricuspid Atresia - chfed.org.uk · Tricuspid Atresia The aim of this information sheet is to explain what Tricuspid Atresia is, what effect it will have on a child and how it can

Documents
Tricuspid valve stenosis

Tricuspid valve stenosis

Education
Reverse endoventricular artificial obturator in tricuspid ... · Reverse endoventricular artificial obturator in tricuspid valve position. Experimental feasibility research study

Reverse endoventricular artificial obturator in tricuspid ... · Reverse endoventricular artificial obturator in tricuspid valve position. Experimental feasibility research study

Documents
Understanding your child's heart Tricuspid atresia

Understanding your child's heart Tricuspid atresia

Documents
Mitral and Tricuspid Repair

Mitral and Tricuspid Repair

Documents
Early Feasibility Study of a Transcatheter Tricuspid Valve ... · BACKGROUND The SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic Chronic Functional Tricuspid

Early Feasibility Study of a Transcatheter Tricuspid Valve ... · BACKGROUND The SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic Chronic Functional Tricuspid

Documents
Tricuspid Valve: CV Profile Tricuspid Atresia, Ebstein, TV ... · Tricuspid Atresia Tricuspid Atresia Tricuspid Atresia Tricuspid Atresia TA with atrial restriction Use venous Doppler

Tricuspid Valve: CV Profile Tricuspid Atresia, Ebstein, TV ... · Tricuspid Atresia Tricuspid Atresia Tricuspid Atresia Tricuspid Atresia TA with atrial restriction Use venous Doppler

Documents
Homepage | STS · Web viewTricuspid valve repair, percutaneous Tricuspid valve repair, surgical Tricuspid valve replacement, surgical Tricuspid valve replacement, transcatheter Tricuspid

Homepage | STS · Web viewTricuspid valve repair, percutaneous Tricuspid valve repair, surgical Tricuspid valve replacement, surgical Tricuspid valve replacement, transcatheter Tricuspid

Documents
TRITON Trial Surgical Treatment of Aortic Stenosis With a ... · 7. Subject with concomitant valve (mitral, tricuspid, or pulmonic) disease requiring repair with an annuloplasty ring

TRITON Trial Surgical Treatment of Aortic Stenosis With a ... · 7. Subject with concomitant valve (mitral, tricuspid, or pulmonic) disease requiring repair with an annuloplasty ring

Documents
Tricuspid Valve Surgery - Peninsula

Tricuspid Valve Surgery - Peninsula

Documents
Practical Manual of Tricuspid Valve Diseases

Practical Manual of Tricuspid Valve Diseases

Documents
Isolated tricuspid valve surgery: timing and indications - STS · tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for

Isolated tricuspid valve surgery: timing and indications - STS · tricuspid valve repair over replacement. Thus, we should not hesitate to consider tricuspid valve replacement for

Documents
Tricuspid atresia in pediatrics

Tricuspid atresia in pediatrics

Health & Medicine
Tricuspid Valve Dysplasia in a Dog · cause of death in puppies. Tricuspid valve dysplasia is characterized by thickening and displacement of the le-aflets of the tricuspid valve,

Tricuspid Valve Dysplasia in a Dog · cause of death in puppies. Tricuspid valve dysplasia is characterized by thickening and displacement of the le-aflets of the tricuspid valve,

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When to perform Tricuspid valve Surgery?

When to perform Tricuspid valve Surgery?

Health & Medicine
TRICENTO Transcatheter Tricuspid Valved Stent Graft

TRICENTO Transcatheter Tricuspid Valved Stent Graft

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