ΑΝΣΙΚΑΣΑΣΑΗ ΣΡΙΓΛΩΧΙΝΑ ΜΕΣΑ ΑΠΟ ΕΠΙΔΙΟΡΘΩΗ ΣΗ ΜΙΣΡΟΕΙΔΟΤ ΒΑΛΒΙΔΑ

ΑΝΣΙΚΑΣΑΣΑΗ ΣΡΙΓΛΩΧΙΝΑ ΜΕΣΑ ΑΠΟ ΕΠΙΔΙΟΡΘΩΗ ΣΗ ΜΙΣΡΟΕΙΔΟΤ ΒΑΛΒΙΔΑ Ανδρέας Κατσαρός Καρδιολόγος Καρδιοχειρουργική Κλινική Γ.Ν.Α. «Ιπποκράτειο» Ομάδα Εργασίας Βαλβιδοπαθειών 2012

ΕΙΑΓΩΓΗ

ΕΙΑΓΩΓΗ Σο πρόβλημα Η βαλβίδα Κλινικές μελέτες υστάσεις Mέθοδοι αντιμετώπισης

ΣΟ ΠΡΟΒΛΗΜΑ A 74-year-old man He is admitted to the hospital for the treatment of exacerbation of congestive heart failure from which he has suffered for the last 2 years He has rheumatic heart disease and had mitral valve replacement with a mechanical bileaflet prosthetic valve for predominantly mitral regurgitation 12 years before his admission Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

ΣΟ ΠΡΟΒΛΗΜΑ He is in chronic atrial fibrillation His neck veins are distended with prominent V waves He has an enlarged pulsating liver and severe peripheral edema Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

ΣΟ ΠΡΟΒΛΗΜΑ Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

ΣΟ ΠΡΟΒΛΗΜΑ TR can result in significant symptoms It remains undertreated Patients are rarely referred for isolated surgical TV repair Most repairs are done in the context of other planned cardiac surgery Rogers J, Bolling S. Circulation 2009; 119:2718-25

ΣΟ ΠΡΟΒΛΗΜΑ Significant TR appears to be a marker for late-stage myocardial and valvular disease Reoperations for recurrent TR are especially high-risk surgical procedures up to 37% inhospital mortality Bernal JM, et al. J Thorac Cardiovasc Surg 2005; 130:498 503

ΣΟ ΠΡΟΒΛΗΜΑ Gammie JS, et al. Circulation 2007; 115:881 7

ΑΝΑΣΟΜΙΚΗ The TV complex consists of: three leaflets (anterior, posterior, and septal) the chordae tendinae two discrete papillary muscles the fibrous tricuspid annulus the right atrial and right ventricular myocardium Silver MD, et al. Circulation 1971; 43:333 48

ΑΝΑΣΟΜΙΚΗ Rogers J, Bolling S. Circulation 2009; 119:2718-25

ΑΝΑΣΟΜΙΚΗ Dilation of the tricuspid annulus occurs primarily in its anterior/posterior (mural) aspect It can result in significant functional TR as a result of leaflet malcoaptation Deloche A, et al. Ann Chir Thorac Cardiovasc 1973; 12:343 9

ΛΕΙΣΟΤΡΓΙΚΗ TR Mascherbauer J, Maurer G. Eur Heart J 2010; 31:2841 3

ΑΝΑΣΟΜΙΚΗ Factors influencing the degree of TR include right ventricular preload, afterload, and right ventricular systolic function The tricuspid annulus is very dynamic and can change markedly with loading conditions Tei C, et al. Circulation 1982; 66:665 71

ΑΝΑΣΟΜΙΚΗ During the cardiac cycle, there is a 19% reduction in annular circumference ( 30% reduction in annular area) with atrial systole Tei C, et al. Circulation 1982; 66:665 71

ΑΝΑΣΟΜΙΚΗ Fukuda S, et al. Circulation 2006; 114(suppl):I-492 8

ΑΝΑΣΟΜΙΚΗ Patients with functional TR generally have a more planar annulus, which is dilated primarily in the septal-lateral direction, resulting in a more circular shape as compared with the elliptical shape in healthy subjects Fukuda S, et al. Circulation 2006; 114(suppl):I-492 8

ΑΙΣΙΟΛΟΓΙΑ TR Primary causes (25%) Rheumatic Myxomatous Ebstein anomaly Endomyocardial fibrosis Endocarditis Carcinoid disease Traumatic (blunt chest injury, laceration) Iatrogenic (pacemaker/defibrillator lead, RV biopsy) Tang GH, et al. Circulation 2006; 114(suppl):I-577 81

ΑΙΣΙΟΛΟΓΙΑ TR Secondary causes (75%) Left heart disease (LV dysfunction or valve disease) resulting in pulmonary hypertension Any cause of pulmonary hypertension (chronic lung disease, pulmonary thromboembolism, left to right shunt) Any cause of RV dysfunction (myocardial disease, RV ischemia/infarction) Tang GH, et al. Circulation 2006; 114(suppl):I-577 81

restriction dilation syndrome Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

ΑΙΣΙΟΛΟΓΙΑ TR Sugimoto T, et al. J Thorac Cardiovasc Surg 1999; 117:463 71

ΚΛΙΝΙΚΕ ΜΕΛΕΣΕ Clinically severe TR has been reported in 23% to 37% of patients after MVR for rheumatic heart disease The incidence of echocardiographically moderate or severe late TR in rheumatic patients is even higher (68%) Izumi C, et al. J Heart Valve Dis 2002; 11:353 6 / Porter A, et al. J Heart Valve Dis 1999; 8:57 62

ΚΛΙΝΙΚΕ ΜΕΛΕΣΕ Moderate or severe TR was reported in as many as 74% of patients 3 years after surgical repair of ischemic MR Dreyfus et al. reported 34% late TR in a group of patients with a mixed etiology for MR degenerative Barlow s (38%) dystrophic (27%) ischemic (13%) rheumatic (11%) Matsunaga A, Duran CM. Circulation 2005; 112:I453 7 / Dreyfus GD, et al. Ann Thorac Surg 2005; 79:127 32

ΚΛΙΝΙΚΕ ΜΕΛΕΣΕ Koukoui et al. reported moderate or severe TR in 15% of patients with MV prolapse and at least moderate MR Tricuspid regurgitation progressed in 14% of the patients during a mean follow-up of 4 years Koukoui D, et al. 55 th Annual Conference of the Israel Heart Society; April, 2008

TR post PM/ICD 248 subjects with echocardiograms before and after device placement TR worsened by 1 grade or more after implant in 24.2% of subjects TR worsening was more common with implantable cardiac defibrillators After lead implantation, 17.8% of patients with baseline mild TR developed moderate to severe TR Kim JB, et al. J Am Soc Echocardiogr 2008; 21:284 7

TR post PM/ICD Five years after successful TV repair 42% of patients with a pacemaker had severe TR Almost double the incidence of those without pacemaker implantation Removing a trans-tricuspid lead and replacing it with an epicardial lead at the time of TV surgery may reduce late repair failure McCarthy PM, et al. J Thorac Cardiovasc Surg 2004; 127:674 85

TR post MVR Patients with mitral stenosis and moderate or severe TR before MVR are more likely to have class III or IV heart failure after a mean follow-up of 8 years compared with patients with mild TR (56% vs 14%) Boyaci A, et al. Angiology 2007; 58:336 42

TR post MVR Ruel et al. reported the risk factors for heart failure and death in 708 patients after MVR Moderate-to-severe TR on echocardiography during 5 years of follow-up was an independent predictor of NYHA functional class III or IV heart failure heart failure-related death all-cause mortality Ruel M, et al. J Thorac Cardiovasc Surg 2004; 128:278 83

TR post MVR Sagie A, et al. J Am Coll Cardiol 1994; 24:696 702

TR post MVR Patients with severe TR after MVR undergoing isolated TV surgery usually have a poor outcome high perioperative mortality (between 11% and 20%) poor late survival no significant improvement in functional capacity King RM, et al. Circulation 1984; 70:I193 7 / Mangoni AA, et al. Eur J Cardiothorac Surg 2001; 19:68 73

TR post MVR The results might be better for patients with preserved RV function referred early for surgery Data regarding the outcome of such an approach and the optimal timing for surgery in such patients is lacking Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

TR post MVR Braunwald NS, Ross J Jr., Morrow AG. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 1967; 35:I63 9 Groves PH, Hall RJ. Late tricuspid regurgitation following mitral valve surgery. J Heart Valve Dis 1992;1:80 6. 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; 79:127 32 Shiran A, Sagie A. J Am Coll Cardiol 2009; 53:401 8

TR post MVR Kwon DA, et al. Am J Cardiol 2006; 98:659 61

ΤΣΑΕΙ

ΑΝΣΙΜΕΣΩΠΙΗ TV annuloplasty adds little time and complexity to MV surgery and results in very few complications In patients with non-severe organic TV disease, TV repair is probably better than replacement Singh SK, et al. Ann Thorac Surg 2006; 82:1735 41 / Tang GH, et al. Circulation 2006; 114:I577 81

ΑΝΣΙΜΕΣΩΠΙΗ The durability of TV repair was assessed by McCarthy et al All TV repair techniques had an immediate failure rate of approximately 14% Patients who had a ring annuloplasty with a semirigid ring (Carpentier-Edwards) had no progression of TR More than 30% of the patients who had a De Vega procedure had significant TR after 8 years McCarthy PM, et al. J Thorac Cardiovasc Surg 2004; 127:674 85

ΑΝΣΙΜΕΣΩΠΙΗ Rogers J, Bolling S. Circulation 2009; 119:2718-25

ΑΝΣΙΜΕΣΩΠΙΗ Boudjemline Y, et al. J Am Coll Cardiol 2005; 46:360 5

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