Anterior papillary muscle septalization
associated with annuloplasty as a new approach
to treat functional tricuspid regurgitation
Jean-Paul Couetil, MD
Henri Mondor Hospital, Creteil, France
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)
Pathophysiology ofet
Functional
TRof
( 2Functional
Populations)
PathophysTopilsky
al.iology
(Topilsky et al.Circ Cardiovasc Imaging, 2012)
TR
Left heart disease
No Left heart disease
Pulmonary hypertension
PHTN-FTR
idiopathic Atrial fibrillation
Id-FTR
RV dysfunction/dilation
RA dysfunction/dilation
Tricuspid Annular dilatation
Tricuspid regurgitation
Annuloplasty: The treatment of choice to cure FTR?
Prevalence of 3+/4+ TR at 5 years
n=2’277 patients
50%
Recurrent TR
40%
44%
30%
24%
20%
19%
16%
10%
12%
0%
Pericardium
DeVega
Technique
Kay
Technique
Flexible
Bands
High incidence of recurrent FTR
Navia, et al. Surgical Management of Secondary Tricuspid Valve Regurgitation. J Thorac Cardiovasc Surg 2010: 1-10
Rigid
Rings
Why do we have recurrent TR?
Residual tricuspid regurgitation early after
tricuspid valve annuloplasty
Apical four-chamber view demonstrating techniques used to
measure TV deformations
J Am Soc Echocardiogr 2007;20: 1236-1242
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
Septalization of APM + annuloplasty to
reverse the physiopatological FTR mecanism?
Areas to Treat
Rationale
- 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)
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
What is the septalization principle?
Functional Tricuspid Regurgitation
To reposition the APM
To reallign the subvalvular apparatus
In one plane
Area to Treat
Surgical Remodeling of right ventricule
What is the septalization goal?
1)Treat the tenting
a)Reduce AB diameter
-Bring the tip of APM
Closer to annular plane
-Bring the tip of APM
closer to the septum
2) Remodle the RV
a)Reduce RV longitudinal
b) And RV transversal
diameters
How works the septalization +annuloplasty to
reverse the mechanism of FTR?
FTR
Annuloplasty + APM-S
RV remodling
APM repositioning
• 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
Surgical Technique of APM-S
Video
1.5 MN
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 coaptation
No more leak
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 :
III :
II :
I:
n=23
n=19
n=5
n=1
48%
40%
10%
2%
• Methods
1/ Population:
Study period was from April 2011 to september 2012
Patients referred for tricuspid valve repair according to ESC guidelines
Guidelines on the management
of valvular heart disease
Vahanian et al., Eur Heart J 2007
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
Patients Characteristics
2/ Echocardiographic data
– Preoperative LVEF 54±13 %
• LVEF > 55 %
• LVEF 35-55 %
• LVEF < 35%
–
–
–
–
–
n=19
n=26
n=3
40%
54%
6%
Tricuspid annulus diameter: 43±7 mm
Tenting area:
2.9±1.6 cm²
Preoperative sPAP:
45±21 mmHg
Preoperative TAPSE
17±5 mm
Tricuspid S wave (DTI)
9±3 cm/sec
– Preoperative TR
IV :
III :
II :
n=19
n=16
n=13
40%
33%
27%
Pre-op Echo assessment
TTE Apical 4-chamber view
Tenting height, Doppler imaging
(video clip)
Patients Characteristics
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
Mitral valve replacement
Aortic valve replacement
Yacoub intervention
Coronary artery bypass grafting
Surgical ablation of atrial fibrillation
Ventricular septal defect closure
n=24
n=8
n=6
n=1
n=4
n=4
n=2
(1 post STEMI, 1 congenital)
– Extracorporeal duration : 118 ± 37 minutes
– Aortic clamping duration: 97 ± 27 minutes
50%
17%
13%
2%
8%
8%
4%
Per operative TEE
(2 video clips)
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
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=0
III : n=1
2%
II : n= 5
0-I : n = 42
10%
88%
98%
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)
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