Tricuspid valve repair

Operating MR, but the patient has TR. What should you do?

We used to say that the surgeon should evaluate the tricuspid valve when mitral valve correction would be performed. This has changed and there is already sufficient evidence to indicate a joint approach at the same time.

In the presence of a patient who has an indication for intervention on the left side of the heart, in the preoperative period, the cardiologist should evaluate the tricuspid valve and decide whether there will be any intervention in it. The decision is not supposed to be made intraoperatively.

Then, a question raises: when should we intervene? And yet, how to intervene?

The indication criteria are well established. In the presence of a tricuspid ring > 40mm (measured by the 4-chamber apical window) and/or in the presence of a moderate or higher degree of regurgitation, this valve should be corrected to avoid future progression and thus, not need after 2 -3 years of having to intervene alone in tricuspid regurgitation.

Then, what should the surgeon do? Ideally, the indication is repairment with a rigid ring… Some surgeons believe that the DeVega technique or even modified DeVega shows similar results. However, we do not have proof in long-term follow-up. In case the rigid ring is not available, valve replacement with a biological prosthesis should be considered, since mechanics have a high incidence of thromboembolic events in this position. Never make “hemirepair” or “loose repair to leave an opening”.

Patients with high degrees of pulmonary hypertension have no contraindication to this correction. The fact that there is pulmonary hypertension alone gives the patient a worse survival prognosis than those who do not have these pressure levels. The only consideration that we must make is in the face of patients with severe RV systolic dysfunction and significant pulmonary arterial hypertension. In this case, we should not perform the tricuspid intervention in view of the high morbidity and mortality during the immediate postoperative period (IPO).

Patients who suffer from chronic atrial fibrillation and do not perform the joint correction, or the ones who do it, with the techniques described above, apart from the rigid ring, have a tendency to have a dramatic evolution to recurrence of major regurgitation and progression to advanced RV systolic dysfunction.

Suggested literature:

1 – Dreyfus GD, Martin RP, Chan KM, et al. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol. 2015 Jun 2;65(21):2331-6.

2 – Chikwe J, Itagaki S, Anyanwu A, et al. Impact of Concomitant Tricuspid Annuloplasty on Tricuspid Regurgitation, Right Ventricular Function, and Pulmonary Artery Hypertension After Repair of Mitral Valve Prolapse. J Am Coll Cardiol. 2015 May 12;65(18):1931-8.

 

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