nishimura, otto et al jacc 2014
TRANSCRIPT
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When to operate?
Luc Pierard, MD, PhD, FESC
Professor of Medicine
Heart Valve Clinic, Department of Cardiology,
University of Liège, Belgium
EUROVALVE, ROMA
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Vahanian, Alfieri et al Eur Heart J 2012
No recommendation for percutaneous commissurotomy in ESC/EACTS Guidelines 2012 Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated, symptomatic severe TS without TR (Class IIb, Level of evidence C) in ACC/AHA Guidelines 2014
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Indications for surgery in tricuspid disease
Vahanian, Alfieri et al Eur Heart J 2012
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Indications for surgery in tricuspid disease
Vahanian, Alfieri et al Eur Heart J 2012
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Tricuspid Regurgitation
Progressive mild or moderate functional TR
‘Stage B)
At the time of left-sided valve surgery
TV repair (IIa)
TV repair (IIb)
PHTN without TA dilatation
TA dilatation*
>40 mm on TTE (>21 mm/m2 ) or >70 mm on direct intraoperative measurement Nishimura, Otto et al JACC 2014
• No RV enlargement • No or mild RA enlargement • No or mild IVC enlargement
with normal respirophasic variation
• Normal RA pressure
• Early annular dilation • Moderate leaflet tethering
TV repair (IIa)
Prior RV HF
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Reoperation for severe, isolated TR after left-sided valve surgery is associated with a perioperative mortality rate of 10% to 25%
The treatment of left-sided valve disease only partially cures TR
Arguments
1 2
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Positive results
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Influence of TV repair in pts undergoing MV replacement - 236 pts with mild to moderate TR - MV replacement
With TV repair = 123 Without TV repair = 113
Lower freedom from moderate/severe TR In pts without TV repair Post-op moderate/severe TR: independent predictor of poorer event free survival
Kim et al 2011
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Secondary TR and RV remodeling after TV repair TV repair is associated with RV reverse remodeling
Van de Veire et al. J Thorac Cardio Surg 2011
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Van de Veire et al. J Thorac Cardio Surg 2011
Effects of TV repair according to TR severity and tricuspid annulus diameter
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Secondary TR and survival after prophylactic TV repair TV repair is associated with better outcome
44 patients undergoing MVS (repair or replacement)
Moderate (≤+2) TR + TA ≥40 mm at preoperative echo
22 MVS+TV repair 22 Isolated MVS
Randomized
Operative mortality 4.4% 4.4% At 12 months F-Up - Moderate/severe TR 0% 28%* - Reverse RV remodeling +++ + - 6MWT +++ +
Benedetto U et al. J Thorac Cardiovasc Surg. 2012
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Benedetto U et al. J Thorac Cardiovasc Surg. 2012
% of improvement of echo measurements
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Controversial results
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Baseline characteristics
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Impact of TV repair at the time of MV replacement
624 pts TV repair if TR>2+
Chan et al Ann Thorac Surg 2009;88:1209-15
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TV repair in pts with TR>2 did not improve outcome
TR 2+ or less may not require repair TA dimension alone should not dictate the performance of TV repair
Chan et al Ann Thorac Surg 2009;88:1209-15
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Secondary TR and Survival after TV repair: adoption of TVP guidelines into daily clinical practice TV repair was associated with excess events
175 patients undergoing MV surgery, 89 TV repair due to TA > 40 mm or TR > gr II Similar characteristics between groups at baseline
TVPlasty +
TVPlasty -
Koppers et al Cong Heart Fail 2013
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Indications for surgery in tricuspid disease
Vahanian, Alfieri et al Eur Heart J 2012
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Tricuspid Regurgitation
Symptomatic severe functional TR
(Stage D)
Preserved RV function, PHTN
not severe
TV repair or TVR (IIb)
Nishimura, Otto et al JACC 2014
• Severe annular dilation (>40 mm or >21 mm/m2 )
• Marked leaflet tethering • RV/RA/IVC dilation • Elevated RA pressure • Diastolic septal flatting
Reoperation
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What do we need to better know?
- Effects of prophylactic TV repair in randomized large-scale trials - Optimize cut-off values for tricuspid annular measurement: which imaging technique? - Identify patients who improve functional class and survival from TV repair after previous left- sided valve surgery
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Take-home message
• When to operate TR remains frequently a difficult decision
• TR persistence or occurrence after left-sided valvular surgery carries a poor outcome
• The prognostic benefit of prophylactic tricuspid
valve annuloplasty remains controversial • Current guidelines are derived from expert
consensus (all recommendations level of evidence C) underlining the urgent need for prospective studies
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Speaker
www.escardio.org/EACVI
3-6 December 2014, Vienna Austria
Main Themes
Three-dimensional imaging Imaging in acute cardiac care
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