Cardio Update
Tricuspidalklappe: The Forgotten ValveRaban Jeger, Oliver Reuthebuch
Kardiologie
Bild frei wählbar !
• Valvular heart disease
• Moderate aortic and mitral regurgitation, mildly reduced LVEF (48%)
• Severe tricuspid regurgitation, dilated right ventricle with reduced RVEF
(TAM 13mm, FAC 24%)
• Atrial fibrillation
• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III
• Refuses surgery
Clinical Case 1
Female Patient, 83 Years
Valvular heart disease
• Aortic valve replacement (ATS 20 mm) 2002, endocarditis 2008, re-do-surgery
with aortic valve replacement (Perimount Magna Ease 21 mm) and tricuspidal
repair (Edwards 4900 26 mm MC3 tricuspid annuloplasty ring) 2009
• Mild mitral stenosis and moderate mitral regurgitation, LVEF 60%
• Severe tricuspid stenosis (RV/RA Gradient: 33 mmHg) and severe regurgitation,
PAHT 45 mmHg, dilated right ventricle with slightly decreased RVEF
Single-vessel coronary disaese
• CABG SVG-RCA 2009
Atrial fibrillation
• DDD-PM 2009, battery replacement 2018
M. Hodgkin 1965
• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III
• High surgical risk
Clinical Case 2
Female Patient, 70 Years
Anatomie
Anatomie
Anatomie
Anatomie
Chirurgische Anatomie (Sternotomie)
Chirurgische Anatomie (Sternotomie)
Chirurgische Anatomie (Sternotomie)
Chirurgische Anatomie (ant.-lat.)
Chirurgische Anatomie (ant.-lat.)
Surgical Techniques
Surgical Techniques
Surgical Techniques
«Clover Technique»
Surgical Techniques
«Pericardial Enlargement» «Double Orifice»
Surgical Techniques
Surgical Techniques
Tricuspid Valve
Prevalence and Surgery
Stuge O., Liddicoat J., et al. JTCS 2006;132:1258-61
22%
63%
0.5%
Temporal trend of isolated tricuspid valve surgery for secondary tricuspid regurgitation in the
USA between 2003 and 2014.
Mohamad Alkhouli et al. Open Heart 2018;5:e000878
Results
Results
Mohamad Alkhouli et al. Open Heart 2018;5:e000878
Results
Results
Tricuspid Valve Regurgitation
Classification and Cause
Rodes-Cabau J et al, Lancet 2016; 388: 2431–42
Tricuspid Valve Regurgitation
Pathophysiology
Deloche et al. Ann Chir Thorac Cardiovasc 1973
Shaikhrezai, et al. Ann Thorac Surg 2017
Functional
(asymmetric
annular
dilatation)
Iatrogenic
(Pacemaker)
Structural
Tricuspid
Regurgitation
Functional Tricuspid Valve Regurgitation
Pathophysiology
Tornos Mas P, Rodríguez-Palomares JF, Antunes MJ. Heart 2015;101:1840–1848
Tricuspid Valve Regurgitation
Regurgitation and Mortality
Nath J et al, J Am Coll Cardiol 2004;43:405–9
Tricuspid Valve Regurgitation
Diagnosis of Severe Valve Regurgitation
Baumgartner H et al, European Heart Journal (2017)38, 2739–2791
Functional Tricuspid Regurgitation
Classification and Treatment
Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6.
ESC Guidelines on Valvular Heart Disease 2017
Regurgitation: Indications for Tricuspid Surgery
Baumgartner H et al, European Heart Journal (2017)38, 2739–2791
Baumgartner H et al, European Heart Journal (2017)38, 2739–2791
ESC Guidelines on Valvular Heart Disease 2017
Indications for Tricuspid Surgery
Severe Functional Tricuspid Regurgitation
Indications for Tricuspid Surgery
Tornos Mas P, Rodríguez-Palomares JF, Antunes MJ. Heart 2015;101:1840–1848
Too Bad Too Good
Symptoms
LVEF
PAHT
• Tricuspid regurgitation is frequent but somewhat difficult to define
• Surgery clearly indicated for good candidates
• Options for „bad“ candidates?
• Surgical mortality higher than for any other valve surgery
• Early prophylactic intervention at the time of left sided disease useful
• As more left side valve disease are getting transcatheter interventions the
negative impact of tricuspid regurgitation on these patients underscores the need
to develop solutions
Tricuspid Valve Regurgitation
Considerations for Transcatheter Therapy
Tricuspid Regurgitation
Interventional Options
Asmarats, L. et al. J Am Coll Cardiol. 2018;71(25):2935–56
Tricento
Forma, TricuClip
Cardioband
Tricinch, Trialign
Tricuspid Regurgitation
The TriValve Registry: Interventional Options
Taramasso M et al, JACC Cardiovasc Interv. 2019 Jan 28;12(2):155-165.
Interventional Options for Tricuspid Regurgitation
TricuClip: Edge-to-Edge Repair
Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814
Interventional Options for Tricuspid Regurgitation
TricuClip: Edge-to-Edge Repair
Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814
• 400 cases performed worldwide
• Transfemoral approach
• Usually 1-2 clips on antero-septal leaflets
(easiest to reach); medial clip has better
results than commissural clip but not always
feasible
• TEE is standard and superior to ICE
• Patient selection is important
• Challenges:
• Leaflets are more fragile, larger
coaptation gap
• Imaging not standardized
• New device with longer arms and a tricuspid
delivery system are needed
Interventional Options for Tricuspid Regurgitation
Tricuclip: Edge-to-Edge Repair
Nickenig G et al, Circulation. 2017 May 9;135(19):1802-1814
Interventional Options for Tricuspid Regurgitation
Trialign: The Scout Trial
Hahn RT et al, J Am Coll Cardiol. 2017 Apr 11;69(14):1795-1806
Interventional Options for Tricuspid Regurgitation
Tricinch
Rosser BA et al, EuroIntervention 2016;12:Y110-Y112
Anterior annulus
of the tricuspid
valve, in
proximity to the
anteroposterior
commissure
Interventional Options for Tricuspid Regurgitation
Cardioband Tricuspid
Schueler R et al, JACC Cardiovasc Interv. 2017 Feb 27;10(4):415-416
• Adjusted
transfemoral
Cardioband
• Proven safety and
performance with
over 90 mitral
patients
• Quick learning
curve to
Cardioband users
• Applying the
surgical gold
standard with a
transfemoral
approach
• Valvular heart disease
• Moderate aortic and mitral regurgitation, mildly reduced LVEF (48%)
• Severe tricuspid regurgitation, dilated right ventricle with reduced RVEF
(TAM 13mm, FAC 24%)
• Atrial fibrillation
• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III
• Refuses surgery
Clinical Case 1
Female Patient, 83 Years
Cardioband Tricuspid (Female Patient, 83 Years)
Cardioband Tricuspid (Female Patient, 83 Years)
Cardioband Tricuspid (Female Patient, 83 Years)
Interventional Options for Tricuspid Regurgitation
Forma
Campelo-Parada F et al, Am Coll Cardiol 2015;66:2475–83
Interventional Options for Tricuspid Regurgitation
Forma
Perlman G et al, JACC Cardiovasc Interv. 2017 Oct 9;10(19):1994-2003
Interventional Options for Tricuspid Regurgitation
Valve-in-Ring, Valve-in-Valve
Valvular heart disease
• Aortic valve replacement (ATS 20 mm) 2002, endocarditis 2008, re-do-surgery
with aortic valve replacement (Perimount Magna Ease 21 mm) and tricuspidal
repair (Edwards 4900 26 mm MC3 tricuspid annuloplasty ring) 2009
• Mild mitral stenosis and moderate mitral regurgitation, LVEF 60%
• Severe tricuspid stenosis (RV/RA Gradient: 33 mmHg) and severe regurgitation,
PAHT 45 mmHg, dilated right ventricle with slightly decreased RVEF
Single-vessel coronary disaese
• CABG SVG-RCA 2009
Atrial fibrillation
• DDD-PM 2009, battery replacement 2018
M. Hodgkin 1965
• Severe symptoms, recurrent right heart decompensations, dyspnea NYHA III
• High surgical risk
Clinical Case 2
Female Patient, 70 Years
TAVI-in-Ring Tricuspid (Female Patient, 70 Years)
TAVI-in-Ring Tricuspid (Female Patient, 70 Years)
Interventional Options for Tricuspid Regurgitation
Tricento
Toggweiler S et al, EuroIntervention. 2018 Sep 20;14(7):758-761
• Bicavally anchored
custom made
covered stent
• Thin porcine
pericardium
leaflets
• Radiopaque
markers for safe
positioning
• Aims to abolish
systolic backflow
in inferior and
superior caval
veins
Interventional Options for Tricuspid Regurgitation
Tricento
Lausberg, HF. European Journal of Cardio-Thoracic Surgery 0 (2017) 1–8
Interventional Options for Tricuspid Regurgitation
Tricento
Lausberg, HF. European Journal of Cardio-Thoracic Surgery 0 (2017) 1–8
Tricento
Tricento
Tricento
• High-risk patients with high perioperative surgery
• Open issues: Indication, patient selection, imaging, assessment of outcomes
• Individual decision on treatment and modality
• Transcatheter tricuspid therapy is feasible with different techniques – their clinical
efficacy is still to be determined
Tricuspid Valve Disease
Take Home Messages
Tricuspid Valve
Anatomy
Kardiologie
AV node
Rodes-Cabau J et al, Lancet 2016; 388: 2431–42
Tendon of Todaro
Koch‘s
Triangle
Transcatheter Treatment of AV Valves
Comparison Mitral - Tricuspid
Kardiologie
Courtesy F. Maisano
Functional Tricuspid Regurgitation
Development, Assessment, Diagnosis, and Treatment
Kardiologie
Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6.