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									TRICUSPID PROSTHESIS
WHEN IS IT NECESSARY?


Miguel Such. Cirujano Cardiovascular.
Jefe de la Unidad de Cirugía Cardiaca.
Área del Corazón del Hospital Universitario Virgen de la Victoria, Málaga.
Área del Corazón del Hospital Xanit Internacional de Málaga.
WHEN TO IMPLANT A TRICUSPID
       PROSTHESIS?



   ¡¡¡NEVER!!!
    ¿NEVER?
       BASE DE DATOS TRICÚSPIDES

 Tricuspid valve surgery: The past 10 years from
  the Nationwie Inpatient Sample (NIS) database.

Christina M. Vassileva, MD, John Shabosky, BA, Theresa Boley,
MSN, Stephen Markwell, MA, and Stephen Hazelrigg, MD.

(J Thorac Cardiovasc Surg 2011;-:1-7)



 28,726 admissions for tricuspid valve surgery
    EVOLUTION OF PROCEDURES




At follow-up: 10.8% of patients had a pace-
   maker (PM) induced rhythm; the mean
TRICUSPID PROSTHESIS
        BASE DE DATOS TRICÚSPIDES

 Tricuspid valve surgery: The past 10 years from
  the Nationwie Inpatient Sample (NIS) database.
                        Conclussions

• There has been dramatic increase in tricuspid interventions
over time.

•Increase in tricuspid repair rates.

•Increase use of bioprostheses for tricuspid replacement.

•The majority     of   tricuspid   operations   with   other   cardiac
procedures
                  FATAL PARADOX

MANAGEMENT OF TRICUSPID VALVE REGURGITATION
 Manuel J Antunes, John B Barlow. Heart 2007;93:271–276


• Hospital mortality for repeat tricuspid valve surgery in
  patients who had a prior cardiac operation may reach 50%.
  Surgery in patients with isolated organic TR should,
  therefore, be delayed.

• High functional class, severe right heart failure, low right
  ventricular ejection fraction, high pulmonary pressure and
  pulmonary arterial resistance are additional risk factors
  when repeating tricuspid surgery.
                       ESTUDIO A 30 AÑOS

Tricuspid valve surgery: a thirty-year assessment of
 early and late outcome.
Thomas Guenther, Christian Noebauer, Domenico Mazzitelli, Raymonde Busch, Peter Tassani-
 Prell , Ruediger Lange. European Journal of Cardio-thoracic Surgery 34 (2008) 402—409


• 416 consecutive patients >18 years with acquired TV disease operated
  on between 1974 and 2003.

• Tric. valve was repaired in 310 patients (74.5%) and replaced in 106
  (25.5%).

• Biological prosthesis was used in 68 patients (64%).

• Patients undergoing replacement showed a significant higher incidence of
  risk factors for operative mortality.

• Prosthetic valve replacement: these patients face a high risk of operative
          DURABILITY OF THE REPAIR

Tricuspid valve repair with an annuloplasty ring
results in improved longterm outcomes.
Tang GHL, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA.
Circulation 2006;114 (Suppl. I):I577—81.

•702 patients underwent TV repair at our institution (1978 to
2003)

•Concomitant procedures consisted of mitral valve surgery in 80%
of patients.

•Clinical and echocardiographic follow-up data were obtained.

•Follow-up was 99% complete and was 5.9 ± 4.9 (mean ± SD)
years long.
          DURABILITY OF THE REPAIR

Tricuspid valve repair with an annuloplasty ring
results in improved longterm outcomes.
Tang GHL, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA.
Circulation 2006;114 (Suppl. I):I577—81.



                 Echocardiographic examination

Ring group:    30% had moderate to severe TR
No ring group: 36% had moderate to severe TR

CONCLUSSION
 30—36% of the patients presented with moderate or severe
                 regurgitation at latest follow-up
  Right-Sided Valve Disease Deserves a Little More
                      Respect
               Charles J. Bruce and Heidi M. Connolly
                 Circulation 2009;119;2726-2734




Kaplan–Meier survival curves for 5223 consecutive patients with TR undergoing
echocardiography at 1 of the 3 laboratories at the Palo Alto (Calif) Veterans Affairs
Heath Care System between August 1998 and July 2002. Survival is significantly
worse in patients with moderate and severe TR.
                    RISKS OF REDOS

Tricuspid valve repair: durability and risk
factors for
failure.
McCarthy PM, Bhudia SK, Rajeswaran Haercher KJ, Lytle BW, Cosgrove DM,
Blackstone EH
J Thorac Cardiovasc Surg 2004;127:674—85.


The discrepancy between the high recurrence rates of TV
regurgitation and the low re-operation rates may be explained
by the fact that TV re-operation is associated with a high
mortality and thus, these patients are managed medically as long
as possible before referral to surgery.
            TRICUSPID PROSTHESIS

 Tricuspid valve surgery: The past 10 years from
  the Nationwie Inpatient Sample (NIS) database.
Christina M. Vassileva, MD, John Shabosky, BA, Theresa Boley,
MSN, Stephen Markwell, MA, and Stephen Hazelrigg, MD.
(J Thorac Cardiovasc Surg 2011;-:1-7)

 Concomitant     tricuspid     replacement     was
associated with significantly higher hospital
mortality than was isolated tricuspid replacement.

               (16.1% vs 10.1% ;P = 0.0001).
  ISOLATED TRICUSPID PROSTHESIS

Tricuspid valve surgery: The past 10 years from
 the Nationwie Inpatient Sample (NIS) database.
        MORTALIDAD POR AÑOS

Tricuspid valve surgery: The past 10 years from
 the Nationwie Inpatient Sample (NIS) database.
              CURRENT SITUATION

Preoperative Factors Associated With Adverse Outcome After
Tricuspid Valve Replacement
Yan Topilsky, MD; Amber D. Khanna, MD; Jae K. Oh, MD; Rick A.
Nishimura, MD; Maurice Enriquez-Sarano, MD; Yang B. Jeon, MD;
Thoralf M. Sundt, MD; Hartzell V. Schaff, MD; Soon J. Park, MD
(Circulation. 2011;123:1929-1939.)

Conclusions—Tricuspid valve replacement for severe
tricuspid regurgitation can be performed with an
acceptable operative mortality (10%) if patients
undergo surgery before the onset of advanced heart
failure symptoms. Late mortality is associated with a
high preoperative Charlson index, short right index
of myocardial performance ratio, and advanced New
York Heart Association class.
Preoperative Factors Associated With Adverse Outcome
After Tricuspid Valve Replacement.
(Circulation. 2011;123:1929-1939.)

               MORTALITY BY FUNCTIONAL CONDITION
               CONCLUSIONS


1. CURRENT MORTALITY OF CONCOMITANT TRICUSPID
   PROSTHESIS IMPLANTATION (NOT REDO) IS ABOUT
   10%.

2. MORTALITY OF ISOLATED TRICUSPID PROSTHESIS
   IMPLANTATION (INCLUDING REDOS) IS ALSO ABOUT
   10%.

3. MORTALITY IS MAINLY RELATED TO THE CLINICAL
   CONDITION OF THE PATIENT. DELAY IN THE
   INDICATION IS THE MAIN CAUSE OF DEATH.
               CONCLUSIONS


• SIGNIFICATIVE RESIDUAL T.R. AFTER REPAIR HAS AN
  UNACCEPTABLE MORTALITY IF LEFT ALONE.

• A GOOD REPLACEMENT IS BETTER THAN A BAD
  REPAIR.

• THERE ARE NOT RANDOMIZED STUDIES COMPARING
  TRICUSPID REPAIR VERSUS REPLACEMENT.
    WHICH PROSTHESIS SHOULD WE
             IMPLANT?

Biological or Mechanical Prostheses in Tricuspid
Position? A Meta-Analysis of Intra-institutional
Results
Giulio Rizzoli, MD, FETCS, Igor Vendramin, MD, Georgios Nesseris, MD,
Tomaso Bottio, MD, Cosimo Guglielmi, MD, and Laura Schiavon, Dstat.
Ann Thorac Surg 2004;77:1607–14




Conclusions. There is not a gold standard in
tricuspid prostheses replacement. Prosthetic
choice is left to the surgeon’s clinical judgment,
taking     into     considerationeach      patient’s
characteristics and needs.
  WHICH PROSTHESIS SHOULD WE
           IMPLANT?

           CONSIDERATIONS

AVERAGE AGE (HISTORICAL) 49,9 ± 11,43 AÑOS

AVERAGE AGE (RECENT)      67.5 ± 11.3 AÑOS


Comparative    studies      between
mechanical and biological prosthesis
have been accomplished in historical
series.
  WHICH PROSTHESIS SHOULD WE
           IMPLANT?

          CONSIDERATIONS

WITH THE AGES OF OUR CURRENT PATIENTS,
IMPLANTATION OF MECHANICAL PROSTHESIS
DOES NOT SEEM TO BE JUSTIFIED.

THERE ARE OTHER FACTORS THAT INFLUENCE
THE DECISION TO IMPLANT A BIOLOGICAL
PROSTHESIS.
            PACEMAKERS AND TRICUSPID
                  PROSTHESIS
Clinical mid-term results after tricuspid valve replacement.
Giorgio Viganò, Andrea Guidotti, Maurizio Taramasso, Andrea Giacomini, Ottavio
 Alfieri
Interactive Cardiovascular and Thoracic Surgery (2010) Volume: 10, Issue: 5, Pages: 709-713




 •Between January 1992 and May 2007, 81 consecutive
 patients underwent TVR (54 re-interventions, 66.7%; 46
 procedures, associated with a left-sided operation,
 56.8%).

 •At follow-up: 10.8% of patients had a pace-maker (PM)
 induced rhythm.
              PACEMAKERS AND TRICUSPID
                    PROSTHESIS
Pacemaker Therapy After Tricuspid Valve Operations: Implications on
Mortality, Morbidity, and Quality of Life
Janne J. Jokinen, Anu K. Turpeinen, Otto Pitkänen, Mikko J. Hippeläinen and Juha E.K. Hartikainen
Ann Thorac Surg 2009;87:1806-1814




The need for a pacemaker after TV operation was high—21% of the
operated-on patients---.
 Conclusions. The need for pacemaker implantation after tricuspid valve
 operations was high. Unexpectedly, the life expectancy of the patients who
 needed a pacemaker postoperatively was higher compared with those who did
 not
PACEMAKERS AND TRICUSPID
      PROSTHESIS




Survival curves of the patients who needed a pacemaker (PM
solid line) and those who did not (PM, dashed line). Early
mortality (deaths within 30 days after the operation) is excluded.
               CONCLUSIONS



• BIOLOGICAL PROSTHESIS ALLOW THE IMPLANTATION
  OF PACEMAKERS AND PROBABLY ICDs.

• THERE ARE NO LONG TERM EVIDENCE ABOUT
  DAMAGES IN THE BIOLOGICAL PROSTHESIS.

• PERICARDIAL PROSTHESIS SHOULD NOT BE AFECTED.
          PERCUTANEOUS ALTERNATIVES

Percutaneous Tricuspid Valve Replacement for a
Stenosed Bioprosthesis
Philip Roberts, MB, ChB; Roberto Spina, MB, BS; Michael Vallely, MB, BS;
Michael Wilson, MB, BS; Brian Bailey, MB, BS; David S. Celermajer, MB, BS, PhD
Circ Cardiovasc Interv 2010;3;e14-e15;




                                       Melody Medtronic Valve
          PERCUTANEOUS ALTERNATIVES

Percutaneous Tricuspid Valve Replacement for a
Stenosed Bioprosthesis
Philip Roberts, MB, ChB; Roberto Spina, MB, BS; Michael Vallely, MB, BS;
Michael Wilson, MB, BS; Brian Bailey, MB, BS; David S. Celermajer, MB, BS, PhD
Circ Cardiovasc Interv 2010;3;e14-e15;




•We describe a case of percutaneous transjugular TVR with
a 22-mm valve in a 28-year-old woman with a history of
bioprosthetic tricuspid valve replacement (27-mm Medtronic
Mosaic valve, Minneapolis, Minn).

•Under fluoroscopic guidance, a percutaneous Medtronic
Melody pulmonary valve was deployed using a 22-mm
Ensemble delivery system.
                 PERCUTANEOUS TRICUSPID
                       PROSTHESIS
Percutaneous tricuspid valve replacement in congenital and
acquired heart disease.
Roberts PA, Boudjemline Y, Cheatham JP, Eicken A, Ewert P, McElhinney DB, Hill SL, Berger F, Khan D, Schranz
D, Hess J,Ezekowitz MD, Celermajer D, Zahn E.
J Am Coll Cardiol. 2011 Jul 5;58(2):117-22




Procedural success was achieved in all 15 patients with the Melody percutaneous
pulmonary valve (Medtronic, Inc., Minneapolis, Minnesota). All had prior TV
surgery and significant stenosis and/or regurgitation of a bioprosthetic TV.

CONCLUSIONS:
In selected cases, patients with prior TV surgery may be candidates for percutaneous
TV replacement.
            PERCUTANEOUS TRICUSPID
                  PROSTHESIS
Heterotopic transcatheter tricuspid valve implantation:
first-in-man application of a novel approach to tricuspid
regurgitation.
Alexander Lauten, Markus Ferrari, Khosro Hekmat, Ruediger Pfeifer,Gudrun Dannberg,
Andreas Ragoschke-Schumm, and Hans R. Figulla
European Heart Journal (2011) 32, 1207–1213




 Transcatheter treatment of severe TR by caval
  valve implantation is feasible resulting in an
  immediate abolition of IVC regurgitation and
         mid-term clinical improvement
        CHOICE OF THE PROSTHESIS
                   CONCLUSIONS

•THERE ARE NO DIFFERENCES IN THE RESULTS BETWEEN
MECHANICAL     AND     BIOLOGICAL PROSTHESIS   IN
RETROSPECTIVE STUDIES.

•ANTICOAGULATION LIMIT QUALITY OF LIFE

•BIOLOGICAL PROSTHESIS  (OR   RINGS) ALLOW   THE
IMPLANTATION OF PACEMAKERS, ICDs AND PERCUTANEOS
PROSTHESIS.




IMPLANTATION OF MECHANICAL PROSTHESIS IN
   THE TRICUSPID POSITION IS NO LONGER
                JUSTIFIED.
       TRICUSPIDE SURGERY HCVV

               HEART TEAM HUVV SERIES



119 PATIENTS (1996-2010)

           84 REPAIRS AND 35 PROSTHESIS

FOLLOW UP (58,1±45,5 months)

OPERATIVE MORTALITY IS 18,5% AND 13,7% IN THE FU

ECHO FU OF 74 PATIENTS (76,3%)

      SEVERE TR IN FOLLOW UP 26%
 TRICUSPID PROSTHESIS
  WHEN IS NECESSARY?
     MAYBE MORE... AND EARLIER
                            THANK YOU
Miguel Such. Cirujano Cardiovascular.
Jefe de la Unidad de Cirugía Cardiaca.
Área del Corazón del Hospital Universitario Virgen de la Victoria, Málaga.
Área del Corazón del Hospital Xanit Internacional de Málaga.

								
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