e chill risk, le ree to s P, Lillihei of “paraeft atrium, m J Cardiol 10 Tuesday 4 and Wednesday 5 October 2011 EACTS Daily News Tuesday 4 October 2011 10:30 Use of centrifugal left ventricular assist device as bridge to candidacy in heart failure with pulmonary hypertension R. S. Kutty, J. Parameshwar, C. Lewis, S. Nair, C. Sudarshan, D. P. Jenkins, J. Dunning, S. Tsui (United Kingdom) 10:45 Early graft failure after heart transplant: Risk factors and implications for improved donor/ recipient matching L. S. De Santo, C. Amarelli, C. Marra, C. Maiello, C. Bancone, F. Grimaldi, G. Nappi, G. Romano (Italy) Invited Discussant: F. Beyersdorf, Freiburg al A, Bove outcome. F, McCafs anomaly gical out- Invited Discussant: J. B. Rich, Norfolk 11:00 , Girod D, sults and nn Thorac overy of a maly) in an 11:15 Is heart transplantation for complex congenital heart disease a good option? A 25-year single centre experience N. Gorislavets, F. Seddio, A. Iacovoni, A. Fontana, R. Sebastiani, A. Terzi, L. Galletti, P. Ferrazzi (Italy) 11:30 Risk factors for post-transplant low output syndrome T. Fujita, K. Toda, J. Kobayashi, Y. Murata, O. Seguchi, H. Ueda, T. Nakatani (Japan) Invited Discussant: G. Bruschi, Milan s of concases with ations. Am ittenbergcalve and vasc Surg Invited Discussant: A. Pavie, Paris 11:45 e disease ctrum that e. Circula- M, Alexi. Modified of mitral orac Surg. Heart transplantation: 25-year single centre experience G. Bruschi, T. Colombo, F. Oliva, L. Botta, G. Pedrazzini, R. Paino, M. Frigerio, L. Martinelli (Italy) Invited Discussant: H. Bittner, Leipzig entation in nd analge- sselin G. A ld patient. header Continued from page 8 Rescue therapy with oral sildenafil decreases the risk of early death due to right ventricular failure in the transplanted heart M. Maruszewski, M. Zakliczynski, J. Nozynski, M. Zembala (Poland) Invited Discussant: T. Carrel, Berne Presentations: 12:00-12:10 Fontan Prize Thoracic Prize Auditorium 1 Report: Fontan Prizewinner 2010 The Honoured Guest Lecture Auditorium 1 12:15-12:45 Tissue-specific adult stem cells Manuel J Antunes Cardiothoracic Surgery, University Hospital, Coimbra, Portugal T ricuspid regurgitation (TR) associated with acquired left sided valve disease is quite frequent, with a described incidence varying from 8% to 35%. In 80% of the cases the TR is “functional” and in 15–20% the lesion is primarily rheumatic (organic). Until fairly recently, it was common belief that tricuspid valve regurgitation ((TR) secondary to left-side heart valve disease would revert with surgical correction of the left heart pathology. This conservative management of TR was based on the theory of the dispensable right ventricle and was vindicated by some comparative series which showed no difference in survival between patients who had and those who did not have tricuspid annuloplasty during mitral and/or aor- tic valve surgery1. It would seem natural that by eliminating the “triggering” factor, after adequate correction of left heart valvulopathy, the tricuspid regurgitation would regress, but this does not always happen. This is in contrast with organic tricuspid pathology which, when significant, always requires correction. Several factors may contribute to the complexity of this problem: (i) Functional tricuspid regurgitation with severely dilated annulus may produce an irreversible deterioration of right ventricular (RV) function. (ii) RV dysfunction may affect postoperative prognosis. (iii) A longer clinical course could result in a greater degree of clinical and hemodynamic deterioration and, thus, greater surgical risk. (iv) Associated right ventricular disease with severe involvement of the tricuspid valve represents advanced disease which has a decisive effect on natural and post-surgical course. (v) There is no reliable method to judge how much is reversible when left-side problems are corrected. (vi) There is a lack of reliable and repeatable methods for measuring and quantifying the degree of tricuspid regurgitation. (vii) There is no satisfactory method to assess true right ventricular function. In fact, the quality of the “repair” of the left sided valvulopathy appears fundamental. Any incomplete or unsatisfactory repair will result in persistence of TR. Even with long-term success of mitral valve surgery, in many cases there is a progressive increase in tricuspid regurgitation The attitude towards the management of the functional TR has changed dramatically in the last decade, essentially as a result of a study published by Dreyfus et al2, confirmed by other more recent studies which found better longterm results in patients with significant TR subjected to tricuspid annuloplasty concomitantly with mitral (more rarely with aortic) surgery. Dreyfus et al went further by concluding that “secondary tricuspid (annular) dilatation is present in a significant number of patients with severe mitral regurgitation without tricuspid regurgitation. It is a progressive disease which does not resolve with correction of the primary lesion alone. Tricuspid annuloplasty at the time of mitral valve surgery in these patients results in improved functional capacity without any increase in perioperative morbidity or mortality”. Since then, the majority of the surgeons have adopted a more aggressive approach to the tricuspid valve. The group o Calafiori3 have found that “an aggressive strategy for functional TR correction, using systematic tricuspid annuloplasty, was able to reduce the TR grade one year after surgery, but mitral surgery alone could not”. Manuel Antunes But the equation has not been completely resolved. For many, it still is difficult to decide to intervene on a functionally normal tricuspid valve just based on a dilated annulus. On the other hand, these concepts have evolved essentially around rheumatic valve disease and may not apply to other pathologies. The Mayo Clinic group4 has just published a paper on functional TR at the time of mitral valve repair for degenerative leaflet prolapse and concluded that “clinically silent nonsevere tricuspid valve regurgitation in patients with degenerative mitral valve disease is unlikely to progress after mitral valve repair. Tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse”, thus calling for a “selective approach”. The 2006 ACC/AHA guidelines consider tricuspid annuloplasty for less than severe TR in patients undergoing mitral valve surgery when there is tricuspid annular dilatation as a class II indication but only when there is severe pulmonary hypertension, and as a class III (not to be done) in the absence of pulmonary hypertension. The next few years should be able to better define the equation. References 1. Pellegrini A, Colombo T, Donatelli F, Lanfranchi M, Quaini E, Russo C, Vitali E. Evaluation and treatment of secondary tricuspid insufficiency. Eur J Cardiothorac Surg. 1992;6:288-96. 2. 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. 3. Calafiore AM, Gallina S, Iacò AL, Contini M, Bivona A, Gagliardi M, Bosco P, Di MauroM. Mitral valve surgery for functional mitral regurgitation: Should moderate-or-more tricuspid regurgitation be treated? A propensity score analysis. Ann Thorac Surg 2009;87:698-70 4. Yilmaz O, Suri RM, Dearani JA et al. Functional tricuspid regurgitation at the time of mitral valve repair for degenerative leaflet prolapse: The case for a selective approach. J Thorac Cardiovasc Surg 2011;142:608-613 header P. Anversa, Boston 14:00 Professional Challenges Auditorium 1 Mitral valve and beyond I Learning objectives: n to become acquainted with new procedures performed only a few times and to understand their potential impact on the treatment of valvular heart disease Moderators: O. Alfieri, Milan; J.L. Pomar, Barcelona 14:00 Videos: Valve-in-ring implantation R. Klautz, Leiden; F. Maisano, Milan; H. Vanermen, Aalst 14:30 Discussion 14:45 Abstracts 14:45 Percutaneous transvenous Melody valve-in-ring procedure for mitral valve replacement T. Shuto, N. Kondo, Y. Dori, K. Koomalsingh, J. Gorman 3rd, R. C. Gorman, M. J. Gillespie (United States) 15:00 Direct access transcatheter mitral annuloplasty with a sutureless and adjustable device F. Maisano1, H. Vanermen2, J. Seeburger3, M. Mack4, V. Falk5, P. Denti1, M. Taramasso1, O. Alfieri1 (1 Italy, 2 Belgium, 3 Germany, 4 USA, 5 Switzerland) Invited Discussant: C. R. Smith, New York Invited Discussant: G. Lutter, Kiel 15:15 Is prophylactic annuloplasty for less than severe functional tricuspid regurgitation really necessary? Value of three-dimensional real-time transoesophageal echocardiography in guiding transapical beating heart mitral valve repair J. Seeburger, T. Noack, S. Leontyev, M. Höbartner, H. Tschernich, J. Ender, M. A. Borger, F. Mohr (Germany) Invited Discussant: S. Bleiziffer, Munich 14:00 Abstracts Auditorium 2 Aortic valve III Learning objectives: n to be informed about current status of techniques of investigation and surgery, as well as risk factors, complications and outcomes in aortic valve disease Moderators: M. Glauber, Massa; M. Cikirikcioglu, Geneva 14:00 Aortic valve repair: State of the art G. El Khoury, Brussels 14:20 Improved risk-assessment in surgery for aortic valve stenosis C. Quarto, M. Dweck, S. Joshi, G. Melina, E. Angeloni, R. Mohiaddin, S. K. Prasad, J. Pepper (United Kingdom) Invited Discussant: M. Kolowca, Rzeszow Continued on page 12 How to prevent progression of functional TR? nary hypertension and previous suture atrial fibrillation (AF) in a sense of a fiannuloplasty (with a three-fold increase nally complex heart failure syndrome, of risk for TR recurrence when suture ina circulus vitiosus has begun. The specific direct mechanisms regarding the TV stead of prosthetic ring annuloplasty had been performed). It has been further are then almost always annular dilatahough the tricuspid valve (TV) is demonstrated that remodelling prostion, dilatation of the right atrium and still known to be the forgotten valve, functional TV disease has re- ventricle and more or less leaflet tether- thetic ring annuloplasty for tricuspid dilatation prevents progression of TR, which cently deserved perceptible more atten- ing. It therefore does not surprise that is undoubtedly the essential part of every tion: relevant tricuspid regurgitation (TR) TV surgery for functional TR has been has been identified as an important and predominantly described concomitant to surgical strategy to prevent TR progresindependent predictor of reduced long- MV procedures (in our patients 34 per- sion and to eradicate existing severe TR, particularly when there is annular dilataterm survival and guidelines have been cent of ischemic MV cases and 43 performulated to improve and standardize cent of all mitral patients with persistent tion and pulmonary hypertension. In the past semi-rigid/rigid rings have the management of TR. However, there AF have concomitant relevant functional shown the highest benefit of TV reTV disease!). is still some uncertainty left, what indiLiterature has identified some factors pair - we worked over nine years with cates how really difficult it is to fully unEdwards MC³ Annuloplasty Ring -, for derstand the complex mechanisms par- of TR recurrence after prior surgery: increased myocardial remodelling, pulmo- the future three-dimensional configuticularly of functional TR and therefore to give reliable general recommendations. It is further believed that there is a significant risk for residual and finally progressive TR when the disease is not treated adequately. Carpentier has shown years ago how perfectly the other atrioventricular valve can be repaired and excellent long-term results are achievable when some general principles are followed, based on precise valvular analyses and of course given, that proven techniques of reconstructive valve surgery are applied. For mitral valve (MV) disease this has meant to understand it in its total complexity, for the understanding of functional TR there are some parallels: myocardial dysfunction induced by some underlying cause(s) brings out secondary changes of pulmonary artery pressure, tissue dilFigure. 1: TV repair for functional TR and annular dilatation (45.8mm) using a Carpentier-Edwards Physio Tricuspid Annuloplasty Ring (size 34). atation, mitral regurgitation (MR) and Stephan Geidel Abteilung für Herzchirurgie, Asklepios Klinik St Georg, Hamburg, Germany T rated material combined with selective flexibility that preserves the natural movements might be an even more physiologic alternative (Figure. 1). Our strategy at AK St. Georg/Hamburg in functional TV disease is that particularly “young” patients (<80 years) with annular dilatation, ischemic cardiomyopathy and/or pulmonary hypertension are treated generously with prosthetic TV ring annuloplasty. Our concept to prevent progression of functional TR is to follow/use “accepted” indications for TV surgery, a proven reconstructive technique with prosthetic ring annuloplasty, a reliable surgical concept in general following the principles of reconstructive valve surgery and standardized AF ablation to induce/support a continuous reverse myocardial remodelling process. Stephan Geidel header Implications in tricuspid annuloplasty rings Marjan Jahangiri Professor of Cardiac Surgery, St George’s Hospital, University of London S econdary tricuspid valve regurgitation (TR) is frequent in patients with chronic left-sided valve disease, particularly associated with atrial fibrillation and pul- gressive. The aim of surgical correction for functional TR is to reduce annular diameter and monary hypertention. Conimprove leaflet coaptation. trary to some beliefs, TR does Placement of an annulonot disappear once the leftsided lesion is corrected. When plasty ring during TV repair is the right ventricle becomes im- associated with a decreased repaired, the process of TR is pro- currence of TR and with im- proved long-term and event free survival compared with repairs not using a ring. Rigid rings provide superior results compared with flexible rings, however, there has been some recent concerns that rigid rings may increase risks of subse-
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