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-