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Anterior papillary muscle septalization associated with annuloplasty as a new approach

Anterior papillary muscle septalization associated with annuloplasty as a new approach to treat functional tricuspid regurgitation Jean-Paul Couetil , MD Henri Mondor Hospital , Creteil , France. Tricuspid Valve: A complex anatomy and pathophysiology. Tricuspid anatomy

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Anterior papillary muscle septalization associated with annuloplasty as a new approach

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  1. Anteriorpapillary muscle septalization associatedwithannuloplasty as a new approach to treatfunctionaltricuspidregurgitation Jean-Paul Couetil, MD Henri Mondor Hospital, Creteil, France

  2. Tricuspid Valve: A complex anatomy and pathophysiology • Tricuspid anatomy - Tricuspid annulus - Subvalvular apparatus (septum + RV free wall) - Tricuspid leaflets • Mecanism of FTR - Tricuspid annular dilatation - True prolapsing leaflet area - PMs displacement (RV remodling: conical  spherical/elliptical)

  3. PathophysTopilsky et al.iology of Functional TR Tricuspid annular dilation Pathophysiology of Functional TR ( 2 Populations) (Topilsky et al.CircCardiovasc Imaging, 2012) No Left heart disease Left heart disease Pulmonary hypertension PHTN-FTR idiopathic Atrial fibrillation Id-FTR RV dysfunction/dilation RA dysfunction/dilation Tricuspid Annular dilatation Tricuspid regurgitation

  4. Annuloplasty: The treatment of choice to cure FTR? Prevalence of 3+/4+ TR at 5 years n=2’277 patients Recurrent TR High incidence of recurrent FTR Navia, et al. Surgical Management of Secondary Tricuspid Valve Regurgitation. J Thorac Cardiovasc Surg 2010: 1-10

  5. Why do we have recurrent TR? Residual tricuspid regurgitation early after tricuspid valve annuloplasty Apical four-chamber view demonstrating techniques used to measure TV deformations J Am Soc Echocardiogr 2007;20:1236-1242

  6. What is the state-of-the Art to prevent from recurrent TR? Tricuspid Leaflet Augmentation- Prof. Dreyfus Clover Technique- Prof. Alfieri These techniques Address TR, but are not a pathophysiological approach

  7. Septalization of APM + annuloplasty to reverse the physiopatological FTR mecanism? Areas to Treat

  8. Rationale - Tricuspid valve tetheringcausingtenting, as a result of outwarddisplacement of PMs in the dilated RV has been reported as a factor decreases the durability of TAP in 12 to 30 % of patients(Fukuda et al. Circulation. 2005; 111:975) - Supported by in vitro studyrevealingthattricuspidannular dilatation and PMsdisplacementindependentlycauseTR(Spinner et al. Circulation 2011;124:920) - Valvular changes are linked to specific RV changes, largest basal dilatation, and normal length (RV conicaldeformation) in the id-FTR versus longest RV ellipticaldeformation/sphericaldeformation in PHTN-FTR (Topilsky et al. CIR Cardiovasc Imaging. 2012 5(3):314)

  9. Principles 1) - Based on the new insights of the complexpathophysiology of the FTR 2) - and Successful technique to relocate and repositionPMs in FMR to reduce mitral valve tenting and leafletstethering 3) - This involves a septalisation of the base of the tricuspidanterior (posterior) papillary muscle

  10. What is the septalization principle? Functional Tricuspid Regurgitation To reposition the APM To reallign the subvalvular apparatus In one plane Area to Treat Surgical Remodeling of right ventricule

  11. What is the septalization goal? 1)Treat the tenting a)Reduce AB diameter -Bring the tip of APM Closer to annular plane -Bring the tip of APM closer to the septum 2) Remodle the RV a)Reduce RV longitudinal b) And RV transversal diameters

  12. How works the septalization +annuloplasty to reverse the mechanism of FTR? FTR Annuloplasty + APM-S RV remodling APM repositioning

  13. 2 pledget-reinforced 4/0 gore-Tex mattress sutures are passed through the base of the anterior papillary muscle close to its free wall insertion . The APM is brought to the septum and the sutures deeply anchored to the septum and firmly attached and tied • Surgical Technique of APM-S

  14. Surgical Technique of APM-S Video 1.5 MN

  15. Surgical correction of the tenting (APM-S + Annuloplasty) and of local leaflets prolapse areas (Neo-Chords) No APM-S = persistent tenting persistent central leak APM-S: good coaptation No more leak

  16. Patients Characteristics 1/ Study Population : • 48 patients ( men 21 ; mean age 63 ± 16 ) • Prior cardiac surgery: n=12 ( 9 redux, 2 tridux, 1 quadridux) • NYHA IV : n=23 48% III : n=19 40% II : n=5 10% I : n=1 2%

  17. Methods 1/ Population: Study period was from April 2011 to september 2012 Patients referred for tricuspid valve repair according to ESC guidelines Guidelines on the management of valvular heart disease Vahanian et al., Eur Heart J 2007

  18. 3/ Echocardiographic Measurements - 2-D TTE standard manner before and after surgery (Vivid7 GE) RVED, RVES,RV fractional area change - 4 chamber view: SL-TV annular diameters, tenting height and area - TR severity assessed by color doppler imaging - TEE per operative before and after procedure - Follow-up TTE at 2, 6 and 12 months

  19. Patients Characteristics 2/ Echocardiographic data • Preoperative LVEF 54±13 % • LVEF > 55 % n=19 40% • LVEF 35-55 % n=26 54% • LVEF < 35% n=3 6% • Tricuspidannulusdiameter: 43±7 mm • Tenting area: 2.9±1.6 cm² • PreoperativesPAP: 45±21 mmHg • Preoperative TAPSE 17±5 mm • Tricuspid S wave (DTI) 9±3 cm/sec • Preoperative TR IV : n=19 40% III : n=16 33% II : n=13 27%

  20. Pre-op Echo assessment TTE Apical 4-chamberview Tentingheight, Doppler imaging (video clip)

  21. Patients Characteristics 3/ Surgery • Anterior Papillary Muscle Septalisation (APM-S) associated with tricuspid ring implantation (Physio-ring size 26 to 34 mm) • Associated procedures: • Mitral valve repair n=24 50% • Mitral valve replacement n=8 17% • Aortic valve replacement n=6 13% • Yacoub intervention n=1 2% • Coronary artery bypass grafting n=4 8% • Surgical ablation of atrial fibrillation n=4 8% • Ventricular septal defect closure n=2 4% • (1 post STEMI, 1 congenital) • Extracorporeal duration : 118 ± 37 minutes • Aortic clamping duration: 97 ± 27 minutes

  22. Per operative TEE (2 video clips) • Before procedure • - Mitral stenosis • - Severe FTR: Tenting height˃ 1.6 cm • RV Dilatation 2) After procedure - MVR replacement - Surgical RV remodling - Annuloplasty - APM-S

  23. 4/ Postoperative results • Death < 30 days : n=2 (1 mesenteric ischemia, 1 septic shock) • TTE at the last follow-up: Incidence of tricuspid regurgitation IV : n=0 III : n=1 2% II : n= 5 10% 0-I : n = 42 88% 98%

  24. Summary/Conclusion - TV is a less and less neglected valve - Recent new insights highlighted a complex physiopathology of FTR which is better understood Persisting issues: - Leaflets tenting correction - Post-OP Persistent and reccurent FTR - accurate per op assessment (echo and surgical)

  25. Conclusion APM-S + annuloplasty approach allows to/is 1) Correct the tenting 2) Remodle the RV 3) Decrease the incidence of early Post-OP Persistent and reccurent FTR 4) Reliable and reproducible technique 5) Preliminary results, needs to be confirmed

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