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Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative.

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Presentation on theme: "Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative."— Presentation transcript:

1 Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation Right Ventricular Function and Pulmonary Artery Hypertension After Degenerative Mitral Repair Joanna Chikwe, MD Professor Department of Cardiovascular Surgery Mount Sinai Medical Center New York New York The senior author of this studiy, Dr David Adams, has the following disclosures.

2 Disclosures The Icahn School of Medicine at Mount Sinai receives royalties from Edwards Lifesciences and Medtronic for Dr. David Adams’ involvement in developing two mitral valve repair rings and one tricuspid valve repair ring. Dr. David Adams is the National Co-Principal Investigator of the CoreValve United States Pivotal Trial, which is supported by Medtronic.  None of the sponsoring organizations had any role in the design and conduct of the study. None of the other authors have any conflicts of interest to disclose..   The senior author of this studiy, Dr David Adams, has the following disclosures.

3 Functional tricuspid regurgitation

4 Rationale Moderate TR is not benign
TR is downgraded by intraoperative TEE Correcting left sided lesions alone does not prevent TR TR repair is safe TR repair is effective

5 Carpentier A J Thorac Cardiovasc Surg 1983 86; 323-337
Specifically Carpentier A J Thorac Cardiovasc Surg ;

6 Carpentier A J Thorac Cardiovasc Surg 1983 86; 323-337

7 Carpentier A J Thorac Cardiovasc Surg 1983 86; 323-337

8 Carpentier A J Thorac Cardiovasc Surg 1983 86; 323-337

9 Consensus Guidelines ACC / AHA 2014 ESC 2012
Class I: Severe TR in patients undergoing left sided valve surgery (C) Class IIa: Mild or moderate secondary TR with dilated annulus* in a patient undergoing left sided valve surgery (C) * >40mm diameter, or 21mm/m2, or >70mm on direct intraoperative measurement Class I: TV repair for severe TR in patients undergoing MVR (C) Class IIa: TV repair for mild, moderate or greater functional TR in patients undergoing MV surgery, when there is prior evidence of right heart failure or TV dilatation* (B) * >40mm diameter, or 21mm/m2, or >70mm on direct intraoperative measurement

10 Consensus Guidelines ACC / AHA 2014 ESC 2012
Class I: Severe TR in patients undergoing left sided valve surgery (C) Class IIa: Mild or moderate secondary TR with dilated annulus* in a patient undergoing left sided valve surgery (C) * >40mm diameter, or 21mm/m2, or >70mm on direct intraoperative measurement Class I: TV repair for severe TR in patients undergoing MVR (C) Class IIa: TV repair for mild, moderate or greater functional TR in patients undergoing MV surgery, when there is prior evidence of right heart failure or TV dilatation* (B) * >40mm diameter, or 21mm/m2, or >70mm on direct intraoperative measurement

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13 Carpentier A J Thorac Cardiovasc Surg 1983 86; 323-337

14

15 Rationale Moderate tricuspid regurgitation is not benign
Correcting left sided lesions alone does not prevent TR TR repair is associated with better functional outcomes TR is downgraded by intraoperative TEE

16 Moderate TR is not benign
Survival (%) N=5223, p<0.001 Days Nath et al., JACC 2004:43;405-9

17 Moderate TR is not benign
Survival (%) N=5223, p<0.001 Days Nath et al., JACC 2004:43;405-9

18 Rationale Moderate tricuspid regurgitation is fairly benign
Correcting left sided lesions alone does not prevent TR Tricuspid repair increases mortality and morbidity TR is downgraded by intraoperative TEE

19 Curing MR does not cure TR
Yilmaz O et al J Thorac and Cardiovasc Surgery 2011

20 Curing MR does not cure TR
Yilmaz O et al J Thorac and Cardiovasc Surgery 2011

21 Curing MR does not cure TR
Yilmaz O et al J Thorac and Cardiovasc Surgery 2011

22 Traditional conservative approach is based on several assumptions:
No repair Traditional conservative approach is based on several assumptions: Moderate tricuspid regurgitation is fairly benign Correcting left sided lesions alone does not prevent TR TR repair is associated with better functional outcomes TR is downgraded by intraoperative TEE

23 TV repair improves functional outcome
Actuarial freedom from CHF Years Chan et al., Annals Thorac Surg 2009:88;

24 TV repair improves functional outcome
Actuarial freedom from CHF Years Chan et al., Annals Thorac Surg 2009:88;

25 Traditional conservative approach is based on several assumptions:
Moderate tricuspid regurgitation is fairly benign Correcting left sided lesions cures functional TR TR repair is associated with better functional outcomes TR is downgraded by intraoperative TEE

26 TR is downgraded under anesthesia
ERO (cm2) Regurgitant volume (ml) Vena contracta (cm) P<0.001 P<0.001 P<0.001 Awake patient Patient under anesthesia Gillan L. Assessment of the Tricuspid Valve. Orlando, Florida 2002 Gemagel et al Circulation 2001; 104: Il-676

27 Methods Inclusion criteria:
Consecutive patients undergoing primary surgery for degenerative mitral regurgitation Exclusion criteria: Aortic valve intervention Severe coronary artery disease Reoperation

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32 Patient characteristics
Variable Mitral repair (n=226) +Tricuspid (n=419) P value Age (years) 52.3 ± 13.5 59.2 ± 12.3 <0.001 Coronary artery disease 12% 11% 0.79 Atrial fibrillation 23% Echocardiographic parameters Pulmonary artery pressure 32mmHg 38mmHg Right ventricular dysfunction 9% 20% Tricuspid regurgitation grade None or trace 59% 31% Mild 42% 52% Moderate or severe 0% 17%

33 Patient characteristics
Variable Mitral repair (n=226) +Tricuspid (n=419) P value Age (years) 52.3 ± 13.5 59.2 ± 12.3 <0.001 Coronary artery disease 12% 11% 0.79 Atrial fibrillation 23% Echocardiographic parameters Pulmonary artery pressure 32mmHg 38mmHg Right ventricular dysfunction 9% 20% Tricuspid regurgitation grade None or trace 59% 31% Mild 42% 52% Moderate or severe 0% 17%

34 Patient characteristics
Variable Mitral repair (n=226) +Tricuspid (n=419) P value Age (years) 52.3 ± 13.5 59.2 ± 12.3 <0.001 Coronary artery disease 12% 11% 0.79 Atrial fibrillation 23% Echocardiographic parameters Pulmonary artery pressure 32mmHg 38mmHg Right ventricular dysfunction 9% 20% Tricuspid regurgitation grade None or trace 59% 31% Mild 42% 52% Moderate or severe 0% 17%

35 Patient characteristics
Variable Mitral repair (n=226) +Tricuspid (n=419) P value Age (years) 52.3 ± 13.5 59.2 ± 12.3 <0.001 Coronary artery disease 12% 11% 0.79 Atrial fibrillation 23% Echocardiographic parameters Pulmonary artery pressure 32mmHg 38mmHg Right ventricular dysfunction 9% 20% Tricuspid regurgitation grade None or trace 59% 31% Mild 42% 52% Moderate 0% 15%

36 Results Overall operative mortality was 0.6% (n=4), mitral repair rate was 99.8% Tricuspid repair was not associated with increased operative mortality or morbidity (p=0.6) There was no difference in implantation of permanent pacemakers in the tricuspid repair group (2.4%, n=10) and the control group (1.3%, n=3) (p=0.6) Clinically significant tricuspid stenosis was not observed (mean gradient 2.1mmHg) 7-year survival for the tricuspid group was 91±5% versus 97±2% in the control group (p=0.1)

37 Freedom from moderate or severe TR
Freedom from moderate TR at 7 years was 97 2% in the tricuspid annuloplasty group compared with 91 3% in the control group (p ) (Figure 1). In Cox proportional hazards regression analysis, tricuspid valve annuloplasty was shown to be an independent predictor of freedom from moderate or greater TR (hazard ratio In subgroup analysis limited to the patients with mild TR, freedom from moderate TR at 7 years was significantly better in the 219 patients who underwent concomitant tricuspid annuloplasty (97 3%) than in the 93 patients who did not (97 3% vs. 83 7%; p ). 226

38 Change in pulmonary artery pressure
Longitudinal TA group worse PAP at baseline After TVA PAP improved significantly by the time of discharge and continued to improve in midterm followup So at 5 years there was no difference between the 2 groups

39 Change in right atrium area
Longitudinal TA group worse PAP at baseline After TVA PAP improved significantly by the time of discharge and continued to improve in midterm followup So at 5 years there was no difference between the 2 groups

40 Change in patients with RV dysfunction
RV dysfunction initially deteriorated postoperatively in both groups (both p < 0.001). This change was more marked in the tricuspid annuloplasty group, in whom the rate of postoperative RV dysfunction before discharge was almost 70%. During follow-up, however, recovery of RV function occurred more rapidly in the tricuspid annuloplasty group, and by 5 years postoperatively, the proportion of patients with normal RV function was similar in both groups

41 Change in patients with RV dysfunction
in the subgroup of patients with pre-discharge RV dysfunction Tricuspid annuloplasty was the Q7 main independent positive predictor of late RV recovery

42 Summary This strategy selects patients with higher prevalence of AF, worse TR grade, more RV dysfunction and tricuspid annular dilatation, and worse pulmonary artery hypertension to undergo concomitant tricuspid valve repair. These patients were more likely to be free from significant TR in long term follow-up, and more likely to see an improvement in their pulmonary artery pressures and right-sided remodelling.

43 Conclusions Tricuspid regurgitation can be nearly eliminated by a strategy of routine ring annuloplasty in patients with moderate TR or tricuspid annular dilatation. This can be achieved without adverse clinical consequences and is associated with evidence of enhanced long-term right-sided remodelling These findings confirm current guideline recommendations for routine tricuspid repair of mild or greater functional tricuspid regurgitation with tricuspid annular dilatation.

44 Conclusions Further, in patients with risk factors for post-operative TR such as AF, pulmonary artery hypertension or RV dysfunction and equivocal echocardiographic findings, our data supports a strategy of direct intra-operative evaluation.

45 Chikwe et al. J Am Coll Cardiol; 2015 (in Press)
Joanna Chikwe MD, Anelechi Anyanwu MD, Shinobu Itagaki MD, David H. Adams MD Chikwe et al. J Am Coll Cardiol; 2015 (in Press)

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