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Imaging for Surgical and Percutaneous Tricuspid Valve Procedures
Tricuspid valve (TV) disease or dysfunction is classified as primary (i.e., intrinsic) valve pathology or secondary. , Secondary or functional tricuspid regurgitation (TR) is the most common cause of TR and represents an important unmet treatment need given its prevalence, adverse prognostic impact, and symptom burden associated with progressive right heart failure. , Indications for intervening on TR are dependent first on determining valve morphology (primary or secondary), TR severity, and right heart size and function, as well as pulmonary artery pressures. , Assessment of these parameters is covered in other chapters. The specific role of imaging in TV interventions is reviewed in this chapter.
Current Guidelines: Indications for Surgical Intervention and Outcomes
Although current class I recommendations for surgical treatment of severe, symptomatic functional TR is at the time of left heart surgery, isolated treatment of the TV is a class IIa indication for treatment. , Multiple studies have shown that the majority of TV surgeries are performed with concomitant left heart surgery with as few as 15% performed as isolated interventions. , A recent 10-year study of 5005 patients in the Unites States National Inpatient Sample showed that isolated TV surgeries increased from 290 in 2004 to 780 in 2013; however, the in-hospital mortality rate remained constant at 8.8%. Compared with patients receiving concomitant left and right valve surgery, patients undergoing isolated TV surgery are older with a higher risk profile and had high rates of postoperative morbidities as well as protracted hospitalizations.
Surgical Tricuspid Valve Intervention
The complex anatomy of the TV has been described in a previous chapter as well as a number of reviews. , Echocardiography is the imaging modality of choice for the initial evaluation of the TV and right heart morphology and function. The surgical TV annulus can be segmented in four regions: aortic, anterior, posterior, and septal. The aortic segment is adjacent to the noncoronary sinus of Valsalva and formed by the hinge lines of the anteroseptal commissure. For both surgical and transcatheter devices, identification of this segment is important to avoid injuring or perforating the aorta but also to anchor annular devices because this region of the annulus contains the most fibrous tissue and has the greatest “pull-through” strength. The atrioventricular (AV) node and the bundle of His cross the septal leaflet attachment 3 to 5 mm posterior to the anteroseptal commissure and should be avoided for both surgical and transcatheter repair procedures. The anterior segment is demarcated by the remaining anterior leaflet hinge line, the posterior segment by the posterior leaflet hinge line and the septal segment by the septal leaflet hinge line. The coronary sinus enters the right atrium consistently near the commissure between the septal and posterior leaflets. Importantly, the anterior and the septal leaflets have the longest circumferential hinge line, so the commissure between these leaflets is also the longest. The septal leaflet, however, is the shortest radial leaflet with chordal attachments to multiple small septal papillary muscles or direct chordal attachments to the septum.
Choosing between surgical TV repair or replacement may be based on a number of factors ( Table 105.1 ). In patients undergoing concomitant TR repair at the time of mitral surgery, persistent severe TR is still present in 11% at 3 months and 17% at 5 years. Reintervention for recurrent TR carries an in-hospital mortality rate of up to 37%. Several clinical, echocardiographic, and procedural risk factors have been associated with failed tricuspid repair at follow-up ( Table 105.2 ). , , , These parameters should help inform procedure choice at the time of surgery, including the use of adjunctive procedures.
TABLE 105.1
Summary of Main Considerations for Type of Tricuspid Valve Surgical Approach
Adapted with permission from Taramasso M, et al: Tricuspid regurgitation: predicting the need for intervention, procedural success, and recurrence of disease, JACC Cardiovasc Imag 12:605–621, 2019.
| TV Repair |
|
|
|
|
| TV Replacement |
|
|
|
RV, Right ventricular; TR, tricuspid regurgitation; TV, tricuspid valve.
TABLE 105.2
Risk Factors Associated With Recurrence of Tricuspid Regurgitation After Tricuspid Annuloplasty a
Adapted with permission from Taramasso M, et al: Tricuspid regurgitation: predicting the need for intervention, procedural success, and recurrence of disease, JACC Cardiovasc Imag 12:605–621, 2019.
| Risk Factors for Recurrence of Significant TR After Repair | Impact on Early TR Recurrence | Impact on Mid and Late TR Recurrence |
|---|---|---|
Echocardiographic Predictors
|
++ + +++ + + |
+ − +++ ++ ++ |
Clinical Predictors
|
+ + + - + + |
+ ++ + +++ +++ + |
Surgical or Procedural Predictors
|
+ + |
+++ + |
COPD, Chronic obstructive pulmonary disease; LV, left ventricular; MV, mitral valve; PH, pulmonary hypertension; PM, pacemaker; TR, tricuspid regurgitation; TV, tricuspid valve.
a + and - represent the presence or absence, respectively, of evidence supporting that data, with more than one + indicating strength of evidence to support it.
Tricuspid Valve Repair Techniques
The two principal surgical methods used to perform tricuspid annuloplasty are suture and ring annuloplasty. Suture annuloplasty methods reduce the size of the tricuspid annulus with a continuous suture to cinch the annulus. With ring annuloplasty, a rigid or semirigid prosthetic, undersized ring is sewn to the tricuspid annulus. Tricuspid annuloplasty rings are incomplete to preserve the native annulus at the site of the AV node and reduce the risk of postoperative heart block. Durability and clinical outcomes of tricuspid repair for secondary TR have been improved with the use of rigid prosthetic ring annuloplasty over suture annuloplasty methods. ,
In the presence of high risk for failure with annuloplasty and advanced leaflet tethering, adjunctive repair techniques may be considered. Leaflet coaptation can be increased by means of anterior leaflet augmentation with the use of an autologous pericardial patch. Leaflet coaptation may also be achieved with double orifice stitch techniques approximating the anterior and septal leaflets or the “clover” technique, which approximates the free edges of the three leaflets, producing a clover-shaped valve opening.
Tricuspid Valve Replacement
TV replacement should be performed when valve repair is not technically feasible in the setting of leaflet pathology or when valve repair carries high risk for early and late recurrence of TR according to known risk factors. The choice of prosthesis type should be individualized, and although bioprostheses are currently favored, there are no differences in survival or adverse events at long-term follow-up in patients receiving mechanical or biological valves.
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