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==Overview==
==Overview==
[[Pulmonary hypertension]] or [[myocardial]] [[disease]] are two factors that affect the treatment of [[secondary TR]]. The surgical approach is considered for selected [[patients]] with severe [[TR]] (stage C,D) at the time of [[surgery]] for [[left-sided valve lesions]] and to prevent later development of severe [[TR]] in [[patients]] with progressive [[TR ]] (Stage B). For selected [[patients]] with isolated [[TR]] (either [[primary TR ]] or [[secondary TR]] attributable to [[annular dilation]] in the absence of [[pulmonary hypertension]] or [[dilated cardiomyopathy]]), [[surgical intervention]] is recommended. [[Mortality rate]] is high in [[patients]] undergone interventions for severe isolated [[TR]] due to [[end-organ damage]] at the time of [[surgery]]. However, outcomes of [[patients]] with severe [[primary TR]] are poor with medical management. Earlier surgery for [[patients]] with severe isolated [[TR]] before the onset of severe [[RV dysfunction]] or [[end-organ damage]] is recommended.
[[Pulmonary hypertension]] or [[myocardial]] [[disease]] are two factors that affect the treatment of [[secondary TR]]. The surgical approach is considered for selected [[patients]] with severe [[TR]] (stage C,D) at the time of [[surgery]] for [[left-sided valve lesions]] and to prevent later development of severe [[TR]] in [[patients]] with progressive [[TR ]] (Stage B). For selected [[patients]] with isolated [[TR]] (either [[primary TR ]] or [[secondary TR]] attributable to [[annular dilation]] in the absence of [[pulmonary hypertension]] or [[dilated cardiomyopathy]]), [[surgical intervention]] is recommended. [[Mortality rate]] is high in [[patients]] undergone interventions for severe isolated [[TR]] due to [[end-organ damage]]. However, outcomes of [[patients]] with severe [[primary TR]] are poor with medical management. Earlier surgery for [[patients]] with severe isolated [[TR]] before the onset of severe [[RV dysfunction]] or [[end-organ damage]] is recommended.


==Surgery==
==Surgery==

Revision as of 09:01, 19 July 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Rim Halaby, M.D. [3] Fatimo Biobaku M.B.B.S [4]

Overview

Pulmonary hypertension or myocardial disease are two factors that affect the treatment of secondary TR. The surgical approach is considered for selected patients with severe TR (stage C,D) at the time of surgery for left-sided valve lesions and to prevent later development of severe TR in patients with progressive TR (Stage B). For selected patients with isolated TR (either primary TR or secondary TR attributable to annular dilation in the absence of pulmonary hypertension or dilated cardiomyopathy), surgical intervention is recommended. Mortality rate is high in patients undergone interventions for severe isolated TR due to end-organ damage. However, outcomes of patients with severe primary TR are poor with medical management. Earlier surgery for patients with severe isolated TR before the onset of severe RV dysfunction or end-organ damage is recommended.

Surgery

Indications for Surgery

Recommendations for intervention in tricuspid valve disease
Primary Tricuspid Regurgitation (Class I, Level of Evidence C):

Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery
Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction

Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):

Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery
Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery

Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):

Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery

Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):

Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery
Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension

Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):

Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients

The above table adopted from 2021 ESC Guideline[1]


 
 
 
 
 
 
 
 
Tricuspid regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Progressive TR (Stage B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
At time of left sided valve surgery
 
 
 
 
 
 
 
 
 
 
 
Severe TR (Stage C,D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Annular dilation> 4 cm, or perior righ heart failure
 
 
 
 
 
 
 
Asymptomatic (Stage C)
 
At time of left sided valve surgery
 
 
Right heart failure (Stage D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
 
 
 
 
 
 
Primary TR with progressive RV dilation or systolic dysfunction
 
TV surgery (1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2b)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary TR
 
 
Prior left sided valve surgery
 
Secondary TR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
Absent of severe pulmonary hypertension or RV systolic dysfunction
 
Poor response to medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2b)
 
 
Annular dilation without pulmonary hypertension or left sided disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TV surgery (2a)
 
 
 
 
 
 
 
 
 
 
 

Abbreviations: TR: Tricuspid Regurgitation; TV: Tricuspid valve; RV: Right ventricle

The above algorithm adapted from 2020 AHA Guideline[2]


Surgical Methods

Annuloplasty

The principal surgical repair for secondary TR is tricuspid annuloplasty. The aim of tricuspid annuloplasty is to improve leaflet coaptation by correcting annular dilatation and restoring annular geometry. The two principle surgical methods are:[8][9]

  • Ring annuloplasty: It is regarded as the standard for surgical repair. The size of the tricuspid annulus is permanently fixed by implantation of a rigid or semi rigid prosthesis, undersized ring, and it is associated with a reduced incidence of late, recurrent tricuspid regurgitation.
  • Suture annuloplasty: It is technically easy and can be done quickly. Also, compared with the ring annuloplasty, a prosthetic implant is not used with suture annuloplasty and the risk of postoperative conduction disturbances is lower.
leaflet coaptation
The transthoracic echocardiography after tricuspid valve repair showed satisfactory leaflet coaptation (A) and repaired papillary muscle (B). Case courtesy by Han-Young Jin et al [10]


Other methods:[8]

  • Adjunctive repair techniques: This may be necessary for augmentation of the effects of the ring annuloplasty in patients with marked leaflet tethering and right ventricular remodeling. The long-term outcomes and durability of these adjunctive techniques are not well established. Types of adjunctive repair techniques are listed in the table below.
Anterior leaflet augmentation using an autologous pericardial patch ''Clover'' technique Double orifice valve technique
Helps improve leaflet coaptation while maintaining leaflet mobility
  • Approximates the free edges of the three leaflets, producing a clover-shaped valve
  • It has also been used to treat selected patients with complex primary tricuspid regurgitation
  • Promising outcomes have been reported
  • Done by passing two sutures from the middle of the anterior portion of the annulus to the septal portion of the annulus, forcing leaflet coaptation
  • Tricuspid valve replacement
  • The initial approach in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased.
  • Transcatheter therapies
    • The safety and feasibility of transcatheter therapies for treating severe tricuspid regurgitation are shown in the study:
    • Three types of transcatheter therapies have recently emerged for treating severe tricuspid regurgitation:
      1. Heterotopic caval transcatheter valve implantation
      2. Transcatheter tricuspid valve annuloplasty
      3. Coaptation device
  • Transcatheter tricuspid valve replacement[12]

References

  1. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
  2. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
  3. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  4. Rogers JH, Bolling SF (May 2009). "The tricuspid valve: current perspective and evolving management of tricuspid regurgitation". Circulation. 119 (20): 2718–25. doi:10.1161/CIRCULATIONAHA.108.842773. PMID 19470900.
  5. Chikwe J, Anyanwu AC (2010). "Surgical strategies for functional tricuspid regurgitation". Semin Thorac Cardiovasc Surg. 22 (1): 90–6. doi:10.1053/j.semtcvs.2010.05.002. PMID 20813324.
  6. Kadri AN, Menon V, Sammour YM, Gajulapalli RD, Meenakshisundaram C, Nusairat L, Mohananey D, Hernandez AV, Navia J, Krishnaswamy A, Griffin B, Rodriguez L, Harb SC, Kapadia S (December 2019). "Outcomes of patients with severe tricuspid regurgitation and congestive heart failure". Heart. 105 (23): 1813–1817. doi:10.1136/heartjnl-2019-315004. PMID 31422359.
  7. Mangoni AA, DiSalvo TG, Vlahakes GJ, Polanczyk CA, Fifer MA (January 2001). "Outcome following isolated tricuspid valve replacement". Eur J Cardiothorac Surg. 19 (1): 68–73. doi:10.1016/s1010-7940(00)00598-4. PMID 11163563.
  8. 8.0 8.1 Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check |pmid= value (help).
  9. Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O (2012). "The growing clinical importance of secondary tricuspid regurgitation". J Am Coll Cardiol. 59 (8): 703–10. doi:10.1016/j.jacc.2011.09.069. PMID 22340261.
  10. "A Case of Traumatic Tricuspid Regurgitation Caused by Multiple Papillary Muscle Rupture".
  11. Altaani HA, Jaber S (June 2013). "Tricuspid Valve Replacement, Mechnical vs. Biological Valve, Which Is Better?". Int Cardiovasc Res J. 7 (2): 71–4. PMC 3987430. PMID 24757625.
  12. Lu FL, An Z, Ma Y, Song ZG, Cai CL, Li BL, Zhou GW, Han L, Wang J, Bai YF, Liu XH, Wang JF, Meng X, Zhang HB, Yang J, Dong NG, Hu SS, Pan XB, Cheung A, Qiao F, Xu ZY (October 2021). "Transcatheter tricuspid valve replacement in patients with severe tricuspid regurgitation". Heart. 107 (20): 1664–1670. doi:10.1136/heartjnl-2020-318199. PMID 33419880 Check |pmid= value (help).

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