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Advances in tricuspid regurgitation

Session presentations
  • Clinical outcome of tricuspid regurgitation. Presented by David MESSIKA-ZEITOUN (Paris, FR) See the slides
  • Assessing the impact on the right ventricle. Presented by Stephan ROSENKRANZ (Koln, DE) See the slides
  • Tricuspid valve surgery: when and how? Presented by Oz M SHAPIRA (Jerusalem, IL) See the slides
  • Percutaneous tricuspid valve implantation after bioprosthetic failure. Presented by Andreas EICKEN (Munich, DE) See the slides
Valvular Heart Diseases

The session dedicated to tricuspid regurgitation (TR) was a joint session between the ESC Working Groups on Grown-Up Congenital Heart Disease and the WG on Valvular Heart Disease.

D. Messika-Zeitoun (Paris, France) reviewed the clinical outcome of TR. One of the determinants of the prognosis of TR is its severity. As for other regurgitant diseases, quantification should integrate different qualitative and quantitative criteria. Quantitative criteria for severe TR are a width of the vena contracta ≥ 7 mm, an effective regurgitant orifice area ≥ 0.45 cm² and a regurgitant volume ≥ 60 ml.
Severe isolated TR is rare but allows for the assessment of the prognosis of TR. A series on 60 patients with severe isolated TR, most often of traumatic origin, reported a 70% incidence of death, surgery or atrial fibrillation after 15 years. Severe TR therefore carries a poor prognosis, even if long-term follow-up is needed to identify adverse events. The main prognostic factor was initial enlargement of right cavities. 
TR may persist and even worsen after left-sided heart valve surgery. At least moderate TR occurring after left-sided heart valve surgery is associated with a lower late survival, mainly after 5 years of follow-up. The initial diameter of the tricuspid annulus is a strong predictive factor of the late occurrence of severe TR after the correction of left-sided heart valve disease, in particular in the mitral position.

S. Rosenkranz (Cologne, Germany) analysed the techniques available for assessing the consequences of TR on the right ventricle.  Due to its particular geometry, right ventricle size and function are difficult to evaluate. Normal values have been proposed in the American Society of Echocardiography guidelines, but the measurement planes should be multiplied and carefully checked. The tricuspid annular plan systolic excursion is a simple measurement which correlates with right ventricular function. To overcome the difficulties linked to the complex three-dimensional shape of the right ventricle, the right ventricle fractional area change has been proposed and has been shown to have a prognostic impact.
Cardiac magnetic resonance imaging is the reference method for the quantification of right ventricular volumes and function because it does not presume any hypotheses on the geometry of right ventricular cavity. However, unlike for congenital heart disease, no threshold of right ventricular volume or function has been identified in relation to the outcome of severe TR. In addition to its limited availability and costs, this limits the usefulness of cardiac magnetic resonance imaging in the diagnostic workup of patients with TR.
Similarly, 3D-echo seems a promising technique to quantify right ventricular volumes and function, but prognostic studies are lacking in the field of TR.

O.M. Shapira (Jerusalem, Israel) reviewed the surgical techniques and indications in the treatment of TR. There is a consensus to favour valve repair in the treatment of functional tricuspid regurgitation. Valve repair consists mainly in tricuspid annuloplasty. The use of prosthetic ring annuloplasty seems to be associated with better long-term results, in particular less risk of residual TR, than suture annuloplasty. In the cases of severe dilatation of the tricuspid annulus, ring annuloplasty alone may be insufficient to correct TR. In these cases, anterior leaflet augmentation may be associated to annuloplasty, in particular if there is severe leaflet tethering.
In patients undergoing left heart valve surgery, severe TR should be corrected, using annuloplasty and/or anterior leaflet augmentation or tricuspid valve replacement if repair is not possible. Mild or moderate TR can be corrected using annuloplasty alone. The correction of mild or moderate TR is indicated when pulmonary artery pressure is > 60 mmHg or when the diameter of tricuspid annulus is > 40 mm or 21 mm/m² of body surface area.

A. Eicken (Munich, Germany) reported a series of percutaneous tricuspid valve implantation for bioprosthetic failure in patients with congenital heart disease. These patients often underwent repeat heart surgery and redo tricuspid surgery and may be at high risk, and this raises problems concerning the choice of valve substitute. Between 2007 and 2012, transcatheter prostheses were implanted in 11 patients: 8 Medtronic Melody prostheses and 3 Edwards Sapien prostheses. All prostheses were successfully implanted and the only procedural complication was a case of femoral vein disruption. One patient experienced a recurrence of severe tricuspid regurgitation 18 months after implantation, without clear explanation. Valve function remained normal in the other cases, with a maximum follow-up of 4 years.

This joint session was a good opportunity to share experience between specialists of valvular heart disease and GUCH who manage patients with tricuspid regurgitation in different heart diseases. It is necessary to draw attention on the tricuspid valve, which seems sometimes to be the “forgotten valve”. The echocardiographic analysis of the tricuspid valve is now well described but improvements are needed in the techniques of measurement of the diameter of the annulus and of right ventricular dimensions and function. The possibility to treat tricuspid valve disease using percutaneous techniques is an interesting perspective in patients who have already undergone several interventions or in those who are at high risk for surgery.




Advances in tricuspid regurgitation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.