The forgotten valve and a population in need ......• The tricuspid valve is: – Complicated but we now understand it better – Difficult to image but 3D echo is an excellent tool

The forgotten valve and a population in need: Understanding

and visualizing the tricuspid regurgitation death spiral

Linda D. Gillam, MD, MPH, MACC, FAHA, FASE

Chair, Department of Cardiovascular Medicine Medical Director, Cardiovascular Service Line

Morristown Medical Center/Atlantic Health System Professor of Medicine

Thomas Jefferson University

Disclosures

None relevant to this presentation Will focus on secondary or functional TR Will set the stage for discussion of new

catheter based therapeutic options

Morristown Medical Center


The tricuspid valve is …..

• Complicated • Difficult to image • Typically secondarily affected • Hemodynamically and clinically significant • Understudied


Leaflets

Papillary muscles and chords

Difficult to image

What leaflet is what? (J Am Soc Echocardiogr 2016;29:74-82.)

3D essential

Functional TR accounts for 85% of TR and has many root causes

Primary RV dysfunction Secondary RV dysfunction

Annular remodeling (atrial fibrillation)


Antonio Mangieri. Circulation: Cardiovascular Interventions. Mechanism and Implications of the Tricuspid Regurgitation, Volume: 10, Issue: 7, DOI: (10.1161/CIRCINTERVENTIONS.117.005043) © 2017 American Heart Association, Inc.

Mas et al Heart 2015

Secondary TR seen in 30-50% of pts with severe MR

A bad combination!


Tricuspid regurgitation management is challenging

• Medical options are limited • Surgical options suboptimal


Medical Management for Secondary TR =

Management of Right Heart Failure and

Underlying Causes


• Diuretics • Sodium restriction • Beta blockers? • ACE/ARB? • Digoxin? • Inotropes • Afterload reduction?

• Limited data to show any impact

on TR

But no mention of TR and

Lead may impact TV function


What happens with intervention for MR with medical management for TR?


We also know

• Isolated TV surgery has high mortality (8-10%) • TV repair at time of left sided surgery has minimal

impact on surgical morbidity and mortality • Anatomic and functional predictors of

residual/recurrent TR have been identified – annular size (40 mm or 21mm/m2 by TTE) – PHTN


Edge to edge mitral repair


TR not addressed

A role for catheter-based intervention?


In summary

• The tricuspid valve is: – Complicated but we now understand it better – Difficult to image but 3D echo is an excellent tool

• Secondary TR is clinically and prognostically important with limited therapeutic options, particularly for the patient in whom surgical intervention would be isolated TV repair – A disease in need of new approaches

Understudied?

Publications (Pubmed)

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Thank you


� DisclosuresThe tricuspid valve is …..Slide Number 4Slide Number 5Slide Number 6Difficult to imageWhat leaflet is what?�(J Am Soc Echocardiogr 2016;29:74-82.)�Slide Number 9Slide Number 10Slide Number 113D essentialSlide Number 13Slide Number 14Slide Number 15Functional TR accounts for 85% of TR and has many root causesSlide Number 17

Slide Number 19Secondary TR seen in 30-50% of pts with severe MR�Slide Number 21Tricuspid regurgitation management is challengingMedical Management for Secondary TR�=�Management of Right Heart Failure �and �Underlying Causes �Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29What happens with intervention for MR with medical management for TR?Slide Number 31Slide Number 32We also knowSlide Number 34Slide Number 35Slide Number 36Edge to edge mitral repairSlide Number 38Slide Number 39A role for catheter-based intervention?Slide Number 41In summaryUnderstudied?Publications (Pubmed)Thank you

Documents

The forgotten valve and a population in need ......• The tricuspid valve is: – Complicated but we now understand it better – Difficult to image but 3D echo is an excellent tool