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Tricuspid Valve Disease

Tricuspid Valve Disease. Dr M C Mayet. Introduction. Rarely affected in isolation Primarily extracardiac symptoms Closely related to right venticular function Influenced by left sided pathology Difficult to evaluate. Anatomy. Changes in tricuspid annulus area. Tricuspid orifice.

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Tricuspid Valve Disease

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  1. Tricuspid Valve Disease Dr M C Mayet

  2. Introduction • Rarely affected in isolation • Primarily extracardiac symptoms • Closely related to right venticular function • Influenced by left sided pathology • Difficult to evaluate

  3. Anatomy

  4. Changes in tricuspid annulus area

  5. Tricuspid orifice 15.3% 16.6% 12.1%

  6. Saddle shape of the tricuspid annulus AS- anteroseptalcommissureAM- midpoint base anterior leaflet AP- anteroposteriorcommissurePM- midpoint base of posterior leaflet SP- posteroseptalcommissureSM-midpoint base of septalleaflet

  7. Leaflets

  8. Anatomical relationships

  9. Pathophysiology Traditional Carpentier type I—normal leaflet motion with annular dilation type II—increased leaflet movement due to leaflet prolapse secondary to chordal rupture or elongation type III—reduced leaflet motion due to leaflet thickening, fused commissures, or leaflet tethering • Organic • Functional

  10. Organic tricuspid valve disease • Infective endocarditis • Rheumatic fever • Degenerative (myxomatous) • Traumatic • Postinfarction • Carcinoid • Appetite suppressing drugs • Endocardialfibroelastosis • Lupus erythematosus • Tumors (myxoma) • Mediastinalfibrosis

  11. Rheumatic

  12. Tricuspid + ass. rheumatic mitral disease • incidence varies widely • Echocardiographic 6% • Postmortem 33% • Surgical findings 11%

  13. Organic tricuspid valve disease • Infective endocarditis • Rheumatic fever • Degenerative (myxomatous) • Traumatic • Postinfarction • Carcinoid • Appetite suppressing drugs • Endocardialfibroelastosis • Lupus erythematosus • Tumors (myxoma) • Mediastinalfibrosis

  14. Functional tricuspid regurgitation Normal Pathological

  15. Functional tricuspid regurgitation Dilated annulus Normal annulus

  16. Clinical features- tricuspid regurgitation • Right sided failure • ascites • hepatosplenomegaly • pulsatileliver • pleural effusions • peripheral edema • Late stages • cachexia • cyanosis • Jaundice • Atrial fibrillation • Jugularvenous distention • swave/fused c &vwaves • prominent y descent • Cardiac examination • S3 • P2 • pansystolicmurmur

  17. Clinical features- tricuspid stenosis • ↑ right atrialpressure • distention of the jugular veins • ascites • pleural effusion • peripheral edema • Jugular venous pulse • prominent a waves • ↓cardiac output • cardiac murmur • mid-diastolic • increases with inspiration • is heard maximally along the leftsternal border • opening snap

  18. Diagnosis • Symptoms usually minimal & overshadowed by left-sided symptoms • Extracardiac symptoms- venous engorgment • Disease mostly silent • Diagnosis previously considered difficult

  19. Apical 4-chamber transthoracic echocardiography Normal mitral valve Normal TV annulus

  20. TTE

  21. Essential preoperative info • Presence of tricuspid valve disease • Organic, functional, or mixed • Degree of regurgitation • Direction of the regurgitantjet • Pulmonary artery peak and mean pressures • Transvalvularpressure gradients • Maximum & minimum annulus diameter • Systolic shortening • Leaflet thickness, mobility, billowing of the leaflet body, & location of the prolapsing free edge toward the RA • Patent foramen ovale

  22. Critical annulus diameter No regurg. Mild regurg. Severe regurg.

  23. Surgical indications • Vast majority- easily repaired • Most lesions (unless severe) not adressed • Unpredictable regression following left sided repair • Problem- lack of detailed preoperative search for Tricuspid disease

  24. Ignoring Tricuspid valve disease • Require a 2nd operation • Postoperative issues • 66% need TV surgery late after Mitral valve surgery

  25. Specific surgical indications • Ass. Left sided valvular lesions • Rheumatic polyvalvular lesions • Traumatic insuffiencies • Infective endocarditis • Functional regurgitation • Cardiac transplant • Ischaemic/idiopathic cardiomyopathy

  26. Surgical approach

  27. Commisurotomy

  28. Valve repair • Repair manouvres are needed less often than for Mitral disease • Non-rheumatic- often repaired • Infective endocarditis- vegetectomy

  29. Tricuspid annuloplasty • Selectively reduce the length of the annulus • Techniques • Bicuspidization • Partial purse-string reduction • Rings or bands

  30. Bicuspidization

  31. DeVega

  32. Rings & bands

  33. Rings & bands

  34. Rings & bands

  35. Open band

  36. Tricuspid replacement • Mitral or tricuspid homografts • Stentedporcine or pericardial valves • Mechanical prosthesis • Excision without replacement

  37. Tricuspid replacement

  38. Homograft replacement • Mitral valve • Sizing- intertrigonal distance • Annuloplasty ring • Beating heart

  39. Prosthetic valve choice • Age • Anticoagulation considerations • Young woman- childbearing years • Social issues must be considered

  40. Conclusions • Results have been poor in the past • Only severe lesions were treated • Valve replacement- exceptional cases • The superior diagnostic tools and surgical techniques available today will enlarge the field of tricuspid surgery

  41. Thank you

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