In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

We use cookies to optimise the design of this website and make continuous improvement. By continuing your visit, you consent to the use of cookies. Learn more

When to perform Tricuspid valve Surgery?

An educational case presented by the Working group on Valvular Heart Disease

Valvular Heart Diseases
Topics: Valvular Heart Diseases
Authors: Julien Dreyfus and David Messika-Zeitoun



Additional contents from webparts:

Case slideshow




Open slideshow in new window

Medical history

  • 55 year old female

  • No cardiovascular risk factors

  • Rheumatic mitral stenosis

    • In 2008 she underwent successful percutaneous mitral valve commissurotomy
    • Referred in 2013 with shortness of breath
  • Physical examination
    • NYHA functional class III
    • Diastolic murmur at the apex
    • Systolic murmur increasing during inspiration
    • Right congestive heart failure
    • Atrial fibrillation

The Mitral valve

The Tricuspid Valve

What is your management strategy?

  1. Repeat percutaneous mitral commissurotomy

  2. Isolated mitral valve replacement

  3. Combined mitral valve replacement + tricuspid surgery (repair or replacement)

  4. More echocardiographic information is needed

What is your management strategy?

  1. Repeat percutaneous mitral commissurotomy

  2. Isolated mitral valve replacement

  3. Combined mitral valve replacement + tricuspid surgery (repair or replacement)

  4. More echocardiographic information is needed

What is your management strategy?

  1. Repeat percutaneous mitral commissurotomy
    One commissure is completely open and MR grade is > 2 - mitral commissurotomy should no be performed

  2. Isolated mitral valve replacement
    Severe tricuspid valve disease. Correction of left-sided disease does not cure the right side

  3. Combined mitral valve replacement + tricuspid surgery (repair or replacement)

  4. More echocardiographic information is needed

 Same patient but  different tricuspid disease…

What is your management strategy?

  1. Repeat percutaneous mitral commissurotomy

  2. Isolated mitral valve replacement

  3. Combined mitral valve replacement + tricuspid surgery (repair or replacement)

  4. More echocardiographic information is needed

What is your management strategy?

  1. Repeat percutaneous mitral commissurotomy

  2. Isolated mitral valve replacement

  3. Combined mitral valve replacement + tricuspid surgery (repair or replacement)

  4. More echocardiographic information is needed

Tricuspid annular diameter

Limitations of surgical strategy based only on degree of TR

1. After isolated mitral valve replacement, 30-50% of patients develop moderate or severe late TR despite absent or mild TR at baseline

Dreyfus G. Ann Thoarc Surg 2005; 79:127-132
Porter A. J Heart Valve Dis 1999; 8:57-62
Izumi C. J Heat Valve Dis 2002; 11:353-6

 Predictive factors for the development of late severe TR
Age
Female gender
Atrial fibrillation
Pulmonary hypertension
Rheumatic disease
Ruel M. J Thorac Cardiovasc Surg 2004; 128:278-83
Song H. Circulation 2007; 116:I246-50
Kim HK. Circulation 2005; 112:I14-9
Matsuyama. Ann Thorac Surg 2003; 75: 1826-8
Porter A. J Heart Valve Dis 1999; 8:57-62
Vincens JJ. Circulation 1995; 92:II 137-42
Levine MJ. Circulation 1989; 79:1061-7

2. Occurrence of moderate / severe late TR is associated with increased morbidity (congestive heart failure) and mortality

3. Surgery for isolated severe TR carries high morbidity and high mortality

Tricuspid annular diameter has been proposed as a more sensitive parameter to guide surgical indications for associated tricuspid valve surgery and to improve long-term morbidity and mortality

Strategy based on annular diameter

  • In 311 patients who underwent mitral valve repair a tricuspid annuloplasty was performed only if the tricuspid annular diameter measured during surgery was greater than twice the normal size (> 70 mm) regardless of the grade of regurgitation.

Dreyfus GD et al. Ann Thorac Surg 2005; 79:127-32

Strategy based on annular diameter

  • This strategy prevented the occurrence of severe late TR and improved the functional status irrespective of the grade of regurgitation.

Comparison of a strategy based on TR degree alone OR TR degree and annular diameter

First cohort: 2002-2004. Associated TR surgery if TR ≥ grade 3




Second cohort: 2004-2006. Associated TR surgery if TR ≥ grade 3 OR annular diameter ≥ 40 mm



  • A strategy based on TR degree and  tricuspid annular diameter for combined tricuspid valve surgery was associated with the absence of worsening of TR and the absence of negative right ventricular remodelling (enlargement)

Associated tricuspid annuloplasty during mitral valve repair / replacement should be considered in patients with tricuspid annular dilatation despite the absence of significant TR to prevent the occurrence of right ventricular dysfunction and advanced heart failure.
 
TV annuloplasty adds little time to the surgery and is associated with very few complications.

Guidelines on the management of valvular heart disease (version 2012)

Vahanian et al. European Heart Journal 2012; 33(19):2451-2496

The best projection in which tricuspid annular diameter should be assessed remains debated but measurements are usually performed in the apical 4-chamber view.

Take home messages

  • During left-sided valve surgery, combined tricuspid valve surgery (annuloplasty or replacement) should be considered if TR grade > 2/4 or tricuspid annular diameter ≥ 40mm or ≥ 21mm/m² of body surface area - especially if predictors of occurrence of late TR are present (age, female gender, atrial fibrillation, pulmonary hypertension or rheumatic disease)