Anterior papillary muscle septalization associated with annuloplasty as a new approach
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Anterior papillary muscle septalization associated with annuloplasty as a new approach to treat functional tricuspid regurgitation
Jean-Paul Couetil, MDHenri Mondor Hospital, Creteil, France
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Tricuspid Valve: A complex anatomy and pathophysiology
• Tricuspid anatomy - Tricuspid annulus - Subvalvular apparatus (septum + RV free wall) - Tricuspid leaflets
• Mecanism of FTR
- Tricuspid annular dilatation - True prolapsing leaflet area - PMs displacement (RV remodling: conical spherical/elliptical)
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PathophysTopilsky et al.iology of Functional TR
Left heart diseaseLeft heart disease
idiopathic Atrial fibrillationId-FTR
idiopathic Atrial fibrillationId-FTR
RA dysfunction/dilationRA dysfunction/dilation
Tricuspid Annular dilatationTricuspid regurgitation
Tricuspid Annular dilatationTricuspid regurgitation
Pulmonary hypertensionPHTN-FTR
Pulmonary hypertensionPHTN-FTR
RV dysfunction/dilationRV dysfunction/dilation
Pathophysiology of Functional TR ( 2 Populations)(Topilsky et al.Circ Cardiovasc Imaging, 2012)
No Left heart diseaseNo Left heart disease
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Annuloplasty: The treatment of choice to cure FTR?
Prevalence of 3+/4+ TR at 5 yearsn=2’277 patients
Navia, et al. Surgical Management of Secondary Tricuspid Valve Regurgitation. J Thorac Cardiovasc Surg 2010: 1-10
Recu
rren
t TR
High incidence of recurrent FTR
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Why do we have recurrent TR?Residual tricuspid regurgitation early after tricuspid valve annuloplasty
J Am Soc Echocardiogr 2007;20: 1236-1242
Apical four-chamber view demonstrating techniques used to measure TV deformations
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What is the state-of-the Art to prevent from recurrent TR?
Tricuspid Leaflet Augmentation- Prof. Dreyfus
Clover Technique- Prof. Alfieri
These techniques Address TR, but are not a pathophysiological approach
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Areas to Treat
Septalization of APM + annuloplasty to reverse the physiopatological FTR mecanism?
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- Tricuspid valve tethering causing tenting, as a result of outward displacement of PMs in the dilated RV has been reported as a factor decreases the durability of TAP in 12 to 30 % of patients (Fukuda et al. Circulation. 2005; 111:975)
- Supported by in vitro study revealing that tricuspid annular dilatation and PMs displacement independently causeTR (Spinner et al. Circulation 2011;124:920)
- Valvular changes are linked to specific RV changes, largest basal dilatation, and normal length (RV conical deformation) in the id-FTR versus longest RV elliptical deformation/spherical deformation in PHTN-FTR (Topilsky et al. CIR Cardiovasc Imaging. 2012 5(3):314)
Rationale
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Principles
1) - Based on the new insights of the complex pathophysiology of the FTR
2) - and Successful technique to relocate and reposition PMs in FMR to reduce mitral valve tenting and leaflets tethering
3) - This involves a septalisation of the base of the tricuspid anterior (posterior) papillary muscle
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What is the septalization principle?
Functional Tricuspid Regurgitation
Surgical Remodeling of right ventricule
Area to Treat
To reposition the APMTo reallign the subvalvular apparatus In one plane
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What is the septalization goal? 1)Treat the tentinga)Reduce AB diameter-Bring the tip of APMCloser to annular plane-Bring the tip of APM closer to the septum
2) Remodle the RVa)Reduce RV longitudinalb) And RV transversal diameters
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How works the septalization +annuloplasty to reverse the mechanism of FTR?FTR Annuloplasty + APM-S
RV remodling
APM repositioning
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• Surgical Technique of APM-S
2 pledget-reinforced 4/0 gore-Tex mattress sutures are passed through the base of the anterior papillary muscle close to its free wall insertion . The APM is brought to the septum and the sutures deeply anchored to the septum and firmly attached and tied
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Surgical Technique of APM-S
Video1.5 MN
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Surgical correction of the tenting (APM-S + Annuloplasty) and of local leaflets prolapse areas (Neo-Chords)
No APM-S = persistent tenting persistent central leak
APM-S: good coaptationNo more leak
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Patients Characteristics
1/ Study Population :
– 48 patients ( men 21 ; mean age 63 ± 16 )– Prior cardiac surgery: n=12 ( 9 redux, 2 tridux, 1 quadridux)
– NYHA IV : n=23 48%III : n=19 40%II : n=5 10%I : n=1 2%
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• Methods1/ Population:Study period was from April 2011 to september 2012Patients referred for tricuspid valve repair according to ESC guidelines
Guidelines on the managementof valvular heart disease
Vahanian et al., Eur Heart J 2007
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3/ Echocardiographic Measurements
- 2-D TTE standard manner before and after surgery (Vivid7 GE)
RVED, RVES,RV fractional area change - 4 chamber view: SL-TV annular diameters, tenting height and area - TR severity assessed by color doppler imaging - TEE per operative before and after procedure - Follow-up TTE at 2, 6 and 12 months
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Patients Characteristics
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Pre-op Echo assessment
TTE Apical 4-chamber viewTenting height, Doppler imaging
(video clip)
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3/ Surgery
– Anterior Papillary Muscle Septalisation (APM-S) associated with tricuspid ring implantation (Physio-ring size 26 to 34 mm)
– Associated procedures:• Mitral valve repair n=24 50%• Mitral valve replacement n=8 17%• Aortic valve replacement n=6 13%• Yacoub intervention n=1 2%• Coronary artery bypass grafting n=4 8%• Surgical ablation of atrial fibrillation n=4 8%• Ventricular septal defect closure n=2 4%
– (1 post STEMI, 1 congenital) – Extracorporeal duration : 118 ± 37 minutes – Aortic clamping duration: 97 ± 27 minutes
Patients Characteristics
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Per operative TEE
1) Before procedure - Mitral stenosis - Severe FTR: Tenting height˃ 1.6 cm RV Dilatation
2) After procedure - MVR replacement - Surgical RV remodling - Annuloplasty - APM-S
(2 video clips)
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4/ Postoperative results
– Death < 30 days : n=2 (1 mesenteric ischemia, 1 septic shock)– TTE at the last follow-up: Incidence of tricuspid regurgitation
IV : n=0III : n=1 2%
II : n= 5 10%0-I : n = 42 88%
98%
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Summary/Conclusion
- TV is a less and less neglected valve - Recent new insights highlighted a complex
physiopathology of FTR which is better understood
Persisting issues: - Leaflets tenting correction - Post-OP Persistent and reccurent FTR - accurate per op assessment (echo and surgical)
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Conclusion
APM-S + annuloplasty approach allows to/is 1) Correct the tenting 2) Remodle the RV 3) Decrease the incidence of early Post-OP Persistent and reccurent FTR 4) Reliable and reproducible technique 5) Preliminary results, needs to be confirmed