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

2. When to perform Tricuspid valve Surgery? A case by the ESC Working Group on Valvular Heart Disease 3. When to perform Tricuspid valve Surgery? 55 year old female No cardiovascular risk factors Rheumatic mitral stenosis In 2008 she underwent successful percutaneous mitral valve commissurotomy Referred in 2013 with shortness of breath Physical examination NYHA functional class III Diastolic murmur at the apex Systolic murmur increasing during inspiration Right congestive heart failure Atrial fibrillation 4. The Mitral Valve Watch videoWatch videoWatch videoWatch videoWatch videoMitral valve area = 1.3 cmMean Gradient = 10 mm Hg 5. The Tricuspid ValveWatch videoWatch video 6. What is you management strategy?1.Repeat percutaneous mitral commissurotomy2.Isolated mitral valve replacement3.Combined mitral valve replacement tricuspid surgery (repair or replacement)+4.More echocardiographic neededisinformation 7. What is you management strategy?1.Repeat percutaneous mitral commissurotomy2.Isolated mitral valve replacement3.Combined mitral valve replacement tricuspid surgery (repair or replacement)+4.More echocardiographic neededisinformation 8. What is you management ?1.Repeat percutaneous mitral commissurotomy One commissure is completely open and MR grade is > 2 - mitral commissurotomy should no be performed 2.Isolated mitral valve replacement Severe tricuspid valve disease. Correction of leftsided disease does not cure the right side 3.Combined mitral valve replacement + tricuspid surgery (repair or replacement) 4.More echocardiographic neededinformationis 9. Same patient but different tricuspid disease Watch video 10. What is you management strategy?1.Repeat percutaneous mitral commissurotomy2.Isolated mitral valve replacement3.Combined mitral valve replacement tricuspid surgery (repair or replacement)+4.More echocardiographic neededisinformation 11. What is you management strategy?1.Repeat percutaneous mitral commissurotomy2.Isolated mitral valve replacement3.Combined mitral valve replacement tricuspid surgery (repair or replacement)+4.More echocardiographic neededisinformation 12. Tricuspid annular diameter 13. Limitations of surgical strategy based only on degree of TR 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline Dreyfus G. Ann Thoarc Surg 2005; 79:127-132 Porter A. J Heart Valve Dis 1999; 8:57-62 Izumi C. J Heat Valve Dis 2002; 11:353-6Predictive factors for the development of late severe TR - Age Ruel M. J Thorac Cardiovasc Surg 2004; 128:278-83 Song H. Circulation 2007; 116:I246-50 - Female gender Kim HK. Circulation 2005; 112:I14-9 - Atrial fibrillation Matsuyama. Ann Thorac Surg 2003; 75: 1826-8 Porter A. J Heart Valve Dis 1999; 8:57-62 - Pulmonary hypertension Vincens JJ. Circulation 1995; 92:II 137-42 - Rheumatic disease Levine MJ. Circulation 1989; 79:1061-7 14. Limitations of surgical strategy based only on degree of TR 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality 15. Limits of a surgical strategy only based on TR degree 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality 3. Surgery for isolated severe TR carries high morbidity and high mortality 16. Limits of a surgical strategy only based on TR degree 1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline 2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality 3. Surgery for isolated severe TR carries high morbidity and high mortality Tricuspid annular diameter has been proposed as a more sensitive parameter to guide surgical indications for associated tricuspid valve surgery and to improve long-term morbidity and mortality 17. Strategy based on annular diameter In 311 patients who underwent mitral valve repair a tricuspid annuloplasty was performed only if the tricuspid annular diameter measured during surgery was greater than twice the normal size (> 70 mm) regardless of the grade of regurgitation.Anteroseptal commissureDreyfus GD et al. Ann Thorac Surg 2005; 79:127-32Anteroposterior commissure 18. Strategy based on annular diameter In 311 patients who underwent mitral valve repair a tricuspid annuloplasty was performed only if the tricuspid annular diameter was greater than twice the normal size (> 70 mm) regardless of the grade of regurgitation. This strategy prevented the occurrence of severe late TR and improved the functional status irrespective of the grade of regurgitation.Dreyfus GD et al. Ann Thorac Surg 2005; 79:127-32 19. Comparison of a strategy based on TR degree alone OR TR degree and annular diameter First cohort: 2002-2004. Associated TR surgery if TR grade 3 Second cohort: 2004-2006. Associated TR surgery if TR grade 3 OR annular diameter 40 mmVan de Veire NR. J Thorac Cardiovasc Surg 2011;141:1431-9 20. Comparison of a strategy based on TR degree alone and TR degree and annular diameter A strategy based on TR degree and tricuspid annular diameter for combined tricuspid valve surgery was associated with the absence of worsening of TR and the absence of negative right ventricular remodelling (enlargement)Van de Veire NR. JTCVS J Thorac Cardiovasc Surg 2011;141:1431-9 21. Associated tricuspid annuloplasty during mitral valve repair / replacement should be considered in patients with tricuspid annular dilatation despite the absence of significant TR to prevent the occurrence of right ventricular dysfunction and advanced heart failure TV annuloplasty adds little time to the surgery and is associated with very few complications 22. Guidelines on the management of valvular heart disease (version 2012)Vahanian et al. European Heart Journal 2012; 33(19):2451-2496 The best projection in which tricuspid annular diameter should be assessed remains debated but measurements are usually performed in the apical 4-chamber view. 23. TAKE HOME MESSAGES During left-sided valve surgery, combined tricuspid valve surgery (annuloplasty or replacement) should be considered if TR grade > 2/4 or tricuspid annular diameter 40mm or 21mm/m of body surface area - especially if predictors of occurrence of late TR are present (age, female gender, atrial fibrillation, pulmonary hypertension or rheumatic disease) 24. Join the ESC Working Group on Valvular Heart Disease and take part in its activities !Membership is FREE!