Tricuspid Valve, New Insights on Repair and Replacement

1
Tricuspid Valve, New Insights on Repair and
Replacement

• Patricia Murphy MD, FRCPC
• Associate Professor
• University of Toronto

2
Lecture Objectives

• Review normal and abnormal tricuspid valve
  anatomy
• Evaluation of organic versus functional tricuspid
  valve regurgitation
• Determine suitability of tricuspid valve for
  repair versus replacement

3
Tricuspid Valve Anatomy

• fibrous annulus
• diameter 28/- 5
• area 7-9cm2
• three valve leaflets
• septal
• anterior
• posterior
• lt 3 mm thickness
• three commissures
• anteroseptal
• anteroposterior
• posteroseptal

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Tricuspid Valve Anatomy

• supported by 3 papillary muscles
• septal and anterior pm joined by moderator band
• apically displaced relative to MV
• distensible, sensitive to loading conditions
• AV node lies beneath septal leaflet in membranous
  septum

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Identification of Leaflet

• ME 4C anterior/left, septal right
• Bicaval posterior/left, anterior/right
• CS view posterior/left, septal/right

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TR Functional VS Organic

• Functional
• normal valve leaflets
• abnormalities of supporting structures
• dilated annulus
• dilated RV
• secondary to
• pulmonary HTN
• MS/MR
• Organic
• abnormalities of leaflets
• congenital
• Ebsteins Anomaly
• acquired
• rheumatic
• myxomatous
• endocarditis
• trauma

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Functional TR

• Functional TR occurs due
• RA enlargement
• annular dilatation
• anterior and posterior leaflets primarily
  involved
• RV enlargement
• displaces papillary muscles
• incomplete leaflet coaptation
• central TR jet

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Functional TR

• annulus size in systole
• normal lt 28 mm
• gt 34 mm end systole
• confirm normal leaflet morphology
• establish etiology
• RA enlargement
• RV enlargement

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TV Repair for Functional TR

• annulus greater than 30
• 3 fingerbreaths
• lt Grade 3 stitch
• gt Grade 3 ring

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DeVega Suture Annuloplasty
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TR Severity

• RA/RV/IVC size
• normal-mild TR
• dilated-severe TR
• Color Flow Doppler
• VC
• gt0.7--severe
• Jet area cm2
• central jet only
• lt5 or gt10
• Jet density
• soft and parabolic-mild
• dense and triangular-severe
• Hepatic vein flow
• systolic predominance-mild
• systolic blunting-moderate
• systolic reversal

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Systolic Flow Reversal in Hepatic Vein
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TV Repair vs Replacement for Organic Disease (n
252)
Periop mortality TV repair 4 TV replacement 22
(p lt 0.001)!
Recurrent moderate or severe TR during follow
up Repair 36 Replacement 7
14
Ebsteins Anomaly

• congenital anomaly of TV
• presents as adult with TR
• apical displacement
• gt 11mm
• 1 or more leaflets
• septal leaflet most often
• TV leaflets dysplastic
• isolated or in association
• ASD
• WPW
• Ventricular inversion

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Ebsteins Anomaly

• large RA
• small atrialized RV
• large anterior leaflet tethered to RV wall
• severe TR, origin below annulus

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TEE Imaging of Ebsteins Anomaly

• ME 4C view
• dilated RA
• small atrializedRV
• tethered leaflets
• apical displacement gt 20 mm
• severe TR