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Pathophysiology and Management of Functional Tricuspid Regurgitation

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Pathophysiology and Pharmacotherapy of Cardiovascular Disease

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Abstract

Functional tricuspid regurgitation (FTR) is an increasingly recognized cause of morbidity and mortality. This clinical entity is most frequently encountered during operations for left-sided heart valve disease, particularly in the setting of functional mitral regurgitation (FMR). Failure to recognize the importance of FTR correction during mitral valve surgery often leads to poor early and late outcomes due to progression of tricuspid regurgitation (TR) and subsequent right heart failure. Consequently, the 2012 ESC/EACTS and 2014 ACC/AHA valvular heart disease guidelines favor a proactive approach to TR correction and highlight the shifting consensus towards more liberal application of surgical therapy. Randomized trials are needed to bolster guideline recommendations further, which are based entirely on retrospective studies. Rigid annuloplasty rings have superior durability and should be used in favor of flexible bands or DeVega-style repairs. Preoperative determinants of clinical outcomes now include echocardiographic parameters of tricuspid valve tenting area and associated right ventricular size and function. Newer percutaneous therapies for FTR may allow less invasive management at the time of percutaneous mitral valve repair or in patients who develop TR late and are at high risk for reoperation. The purpose of this chapter is to review the pathophysiology and current surgical management of functional tricuspid regurgitation, as well as emerging transcatheter therapies.

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Abbreviations

ACC:

American College of Cardiology

AHA:

American Heart Association

EACTS:

European Association for Cardiothoracic Surgery

ESC:

European Society of Cardiology

FTR:

Functional tricuspid regurgitation

STS:

Society of Thoracic Surgeons

References

  1. Singh SK, Tang GH, Maganti MD, Armstrong S, Williams WG, David TE, et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg. 2006;82(5):1735–41; discussion 1741.

    Article  PubMed  Google Scholar 

  2. Bernal JM, Morales D, Revuelta C, Llorca J, Gutierrez-Morlote J, Revuelta JM. Reoperations after tricuspid valve repair. J Thorac Cardiovasc Surg. 2005;130(2):498–503.

    Article  PubMed  Google Scholar 

  3. Deloche A, Guerinon J, Fabiani JN, Morillo F, Caramanian M, Carpentier A, et al. Anatomical study of rheumatic tricuspid valve diseases: application to the study of various valvuloplasties. Ann Chir Thorac Cardiovasc. 1973;12(4):343–9.

    CAS  PubMed  Google Scholar 

  4. Fukuda S, Saracino G, Matsumura Y, Daimon M, Tran H, Greenberg NL, et al. Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation. 2006;114(1 Suppl):I492–8.

    PubMed  Google Scholar 

  5. Suga H, Sagawa K, Shoukas AA. Load independence of the instantaneous pressure-volume ratio of the canine left ventricle and effects of epinephrine and heart rate on the ratio. Circ Res. 1973;32(3):314–22.

    Article  CAS  PubMed  Google Scholar 

  6. Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119(20):2718–25.

    Article  PubMed  Google Scholar 

  7. Yilmaz O, Suri RM, Dearani JA, Sundt 3rd TM, Daly RC, Burkhart HM, et al. Functional tricuspid regurgitation at the time of mitral valve repair for degenerative leaflet prolapse: the case for a selective approach. J Thorac Cardiovasc Surg. 2011;142(3):608–13.

    Article  PubMed  Google Scholar 

  8. Matsuyama K, Matsumoto M, Sugita T, Nishizawa J, Tokuda Y, Matsuo T. Predictors of residual tricuspid regurgitation after mitral valve surgery. Ann Thorac Surg. 2003;75(6):1826–8.

    Article  PubMed  Google Scholar 

  9. Desai RR, Vargas Abello LM, Klein AL, Marwick TH, Krasuski RA, Ye Y, et al. Tricuspid regurgitation and right ventricular function after mitral valve surgery with or without concomitant tricuspid valve procedure. J Thorac Cardiovasc Surg. 2013;146(5):1126–32.e10.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. 2005;112(9 Suppl):I453–7.

    PubMed  Google Scholar 

  11. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg. 2005;79(1):127–32.

    Article  PubMed  Google Scholar 

  12. Chopra HK, Nanda NC, Fan P, Kapur KK, Goyal R, Daruwalla D, et al. Can two-dimensional echocardiography and Doppler color flow mapping identify the need for tricuspid valve repair? J Am Coll Cardiol. 1989;14(5):1266–74.

    Article  CAS  PubMed  Google Scholar 

  13. Van de Veire NR, Braun J, Delgado V, Versteegh MI, Dion RA, Klautz RJ, et al. Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J Thorac Cardiovasc Surg. 2011;141(6):1431–9.

    Article  PubMed  Google Scholar 

  14. De Vega NG. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol. 1972;25(6):555–6.

    PubMed  Google Scholar 

  15. Kay JH, Maselli-Campagna G, Tsuji KK. Surgical treatment of tricuspid insufficiency. Ann Surg. 1965;162:53–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004;127(3):674–85.

    Article  PubMed  Google Scholar 

  17. Navia JL, Nowicki ER, Blackstone EH, Brozzi NA, Nento DE, Atik FA, et al. Surgical management of secondary tricuspid valve regurgitation: annulus, commissure, or leaflet procedure? J Thorac Cardiovasc Surg. 2010;139(6):1473–82.e5.

    Article  PubMed  Google Scholar 

  18. Carpentier A, Deloche A, Hanania G, Forman J, Sellier P, Piwnica A, et al. Surgical management of acquired tricuspid valve disease. J Thorac Cardiovasc Surg. 1974;67(1):53–65.

    CAS  PubMed  Google Scholar 

  19. Yiu KH, Wong A, Pu L, Chiang MF, Sit KY, Chan D, et al. Prognostic value of preoperative right ventricular geometry and tricuspid valve tethering area in patients undergoing tricuspid annuloplasty. Circulation. 2014;129:87–92.

    Article  PubMed  Google Scholar 

  20. Topilsky Y, Khanna AD, Oh JK, Nishimura RA, Enriquez-Sarano M, Jeon YB, et al. Preoperative factors associated with adverse outcome after tricuspid valve replacement. Circulation. 2011;123(18):1929–39.

    Article  PubMed  Google Scholar 

  21. Kilic A, Saha-Chaudhuri P, Rankin JS, Conte JV. Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the society of thoracic surgeons database. Ann Thorac Surg. 2013;96:1546–52.

    Article  PubMed  Google Scholar 

  22. Marquis-Gravel G, Bouchard D, Perrault LP, Page P, Jeanmart H, Demers P, et al. Retrospective cohort analysis of 926 tricuspid valve surgeries: clinical and hemodynamic outcomes with propensity score analysis. Am Heart J. 2012;163(5):851–8.e1.

    Article  PubMed  Google Scholar 

  23. LaPar DJ, Mulloy DP, Stone ML, Crosby IK, Lau CL, Kron IL, et al. Concomitant tricuspid valve operations affect outcomes after mitral operations: a multiinstitutional, statewide analysis. Ann Thorac Surg. 2012;94(1):52–7; discussion 58.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Ro SK, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery. J Thorac Cardiovasc Surg. 2013;146(5):1092–7.

    Article  PubMed  Google Scholar 

  25. Teman NR, Huffman LC, Krajacic M, Pagani FD, Haft JW, Bolling SF. “Prophylactic” tricuspid repair for functional tricuspid regurgitation. Ann Thorac Surg. 2014;97(5):1520–4.

    Article  PubMed  Google Scholar 

  26. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;63(22):2438–88.

    Article  PubMed  Google Scholar 

  27. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42(4):S1–44.

    Article  PubMed  Google Scholar 

  28. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007;115(7):881–7.

    Article  PubMed  Google Scholar 

  29. Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg. 2009;88(6):1845–50.

    Article  PubMed  Google Scholar 

  30. Dvir D, Webb JG, Bleiziffer S, Pasic M, Waksman R, Kodali S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312(2):162–70.

    Article  CAS  PubMed  Google Scholar 

  31. Bhamidipati CM, Scott Lim D, Ragosta M, Ailawadi G. Percutaneous transjugular implantation of MELODY(R) valve into tricuspid bioprosthesis. J Card Surg. 2013;28(4):391–3.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Tzifa A, Momenah T, Al Sahari A, Al Khalaf K, Papagiannis J, Qureshi SA. Transcatheter valve-in-valve implantation in the tricuspid position. Euorintervention. 2014;10:995–9.

    Google Scholar 

  33. Cheung AW, Gurvitch R, Ye J, Wood D, Lichtenstein SV, Thompson C, et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J Thorac Cardiovasc Surg. 2011;141(3):711–5.

    Article  PubMed  Google Scholar 

  34. Lauten A, Ferrari M, Hekmat K, Pfeifer R, Dannberg G, Ragoschke-Schumm A, et al. Heterotopic transcatheter tricuspid valve implantation: first-in-man application of a novel approach to tricuspid regurgitation. Eur Heart J. 2011;32(10):1207–13.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Laule M, Stangl V, Sanad W, Lembcke A, Baumann G, Stangl K. Percutaneous transfemoral management of severe secondary tricuspid regurgitation with Edwards Sapien XT bioprosthesis: first-in-man experience. J Am Coll Cardiol. 2013;61(18):1929–31.

    Article  PubMed  Google Scholar 

  36. Rogers JH, Bolling SF. Valve repair for functional tricuspid valve regurgitation: anatomical and surgical considerations. Semin Thorac Cardiovasc Surg. 2010;22(1):84–9.

    Article  PubMed  Google Scholar 

  37. Daneault B, Williams MR, Leon MB, Paradis JM, Kodali SK. Transcatheter tricuspid valve-in-valve replacement resulting in 4 different prosthetic heart valves in a single patient. J Am Coll Cardiol. 2013;61(2):e3.

    Article  PubMed  Google Scholar 

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Conflicts of Interest

Jason H. Rogers is a consultant for St Jude Medical, Edwards, and Medtronic. S.F. Bolling is a consultant for St. Jude Medical, Sorin-Carbomedics, Medtronic, and Edwards Lifesciences.

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Authors and Affiliations

  1. Interventional Cardiology, Division of Cardiovascular Medicine, University of California, Davis Medical Center, 4860 Y Street, Suite 2820, Sacramento, CA, 95817, USA

    Jason H. Rogers MD, FACC, FSCAI

  2. University of Michigan Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA

    Steven F. Bolling MD

Authors
  1. Jason H. Rogers MD, FACC, FSCAI
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  2. Steven F. Bolling MD
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Corresponding author

Correspondence to Jason H. Rogers MD, FACC, FSCAI .

Editor information

Editors and Affiliations

  1. Center for Drug Evaluation and Research Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, Maryland, USA

    Gowraganahalli Jagadeesh

  2. Pharmacology Unit, AIMST University, Bedong, Malaysia

    Pitchai Balakumar

  3. Center for Drug Evaluation and Research Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, Maryland, USA

    Khin Maung-U

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Rogers, J.H., Bolling, S.F. (2015). Pathophysiology and Management of Functional Tricuspid Regurgitation. In: Jagadeesh, G., Balakumar, P., Maung-U, K. (eds) Pathophysiology and Pharmacotherapy of Cardiovascular Disease. Adis, Cham. https://doi.org/10.1007/978-3-319-15961-4_56

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  • DOI: https://doi.org/10.1007/978-3-319-15961-4_56

  • Publisher Name: Adis, Cham

  • Print ISBN: 978-3-319-15960-7

  • Online ISBN: 978-3-319-15961-4

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