David C. Reineke*
Eva RoostFlorian SchoenhoffMiralem PasicAlex Kadner
Lars Englberger
Thierry P. Carrel- Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland
Introduction
Tricuspid valve disease can either be stenotic or regurgitant. While stenotic lesions are very rare and mainly caused by rheumatic fever or carcinoid disease, the most common disease of the tricuspid valve is regurgitation (1). As with all valves, primary and secondary entities exist. This opinion paper will focus on the most frequent pathology, the functional tricuspid regurgitation (FTR), which primarily is considered as disease of the right ventricle.
Why Do We Talk About the Forgotten Valve?
Most editorials on the tricuspid valve speak about “the forgotten or untreated valve.” Why is that so?
In our view, four facts are responsible for this development:
1. In the early seventies right sided endocarditis due to intravenous drug abuse was treated simply by surgically removing the valve, leaving behind torrential tricuspid regurgitation (TR). This was supported surprisingly well. Long-term data was of course scarce due to this selected patient population.
2. Initially it was believed that left-sided valve surgery would resolve the problem of the tricuspid valve. TR was generally thought to be a bystander with the main focus on the correction of left sided pathology. However it has been shown that TR does not resolve following left-sided heart surgery with relevant influence on long-term survival.
3. For a long time the focus was put on TR alone. Data has shown that not only the presence of TR represents a significant risk factor for severe TR during follow-up after mitral valve surgery, but that annular dilatation alone is a predictive factor for later TR.
4. In the pioneering days of heart surgery it was all about survival and TR was never demonstrated to adversely influence early outcome. This observation applied for the whole complex of right sided pathologies which only become relevant as patients' survival of left sided heart disease has considerably improved. A similar development can be seen in patients suffering from chronic pulmonary embolic disease. Right heart disease is just not as “appealing” as left heart disease.
What Do the Guidelines Tell Us?
Guidelines supported this scientific and practical deficit on therapy for several decades. While American and European guidelines where relatively fast in listing a class I indication to perform tricuspid valve repair for severe TR in patients who are undergoing mitral valve (MV) surgery both guidelines where for a long period quite silent about performing concomitant tricuspid valve surgery for coronary bypass, aortic valve replacement or other cardiac surgery (2, 3).
The ESC Guidelines also listed tricuspid surgery as a Class I indication in the case of severe primary TR (or tricuspid stenosis) with symptoms and without severe RV dysfunction (3). The US guidelines on the other hand only listed this scenario as “reasonable” and as class IIa indication (2). This is one of the rare exceptions where valve disease with symptoms is not listed as a Class I indication for surgery in the guidelines (2) and reflects the general reluctance to operate on some of these patients who have already developed irreversible right ventricular (RV) dysfunction.
Patients with FTR remain asymptomatic for a long time despite considerably impaired right ventricular function (4). As a result the population with a potential indication to treat TR is of advanced age, has often already had cardiac surgery and suffers from extensive RV dysfunction. This is actually a shame as surgery performed in early stages of the disease is relatively easy and a straight forward procedure with very acceptable operative risk (5).
Forgotten or Just Unnoticed?
Despite talk of the “forgotten valve,” already 20 years ago, renowned specialists in the field had the following messages which went unnoticed (5, 6):
• Tricuspid annular dilatation is more reliable than regurgitation and represents a more consistent landmark.
• TR alone is a unreliable parameter as it very much depends on several factors like volume status, preload, afterload and right ventricular dysfunction.
• TR is a continuing process, worsening despite treatment of left-sided pathologies. Already then the group around Gilles Dreyfus were able to show progression of the disease in 30% of patients during a follow-up between 5 and 15 years.
Treating annular dilatation beyond a given size improves functional status and there is a clear trend toward better survival compared to patients who did not receive treatment.
This concept is supported by several groups including the American College of Cardiology/American Heart Association guidelines who included a type IIa recommendation for patients with a threshold diameter of 40 mm (7–13).
The need of treatment of this polymorbid patient population has resulted in the development of a variety of interventional devices. But, it becomes evident that while we are again able to quite effectively treat left sided pathologies with TAVI and mitral devices, right-sided therapy options still stay far behind.
In the current ESC/ECTS guidelines with updated indications for the evaluation and surgical intervention in patients with TR, interventional strategies have only found their place in the chapter “Gaps in evidence”: “The potential role of transcatheter tricuspid valve treatment in high-risk patients needs to be determined (14).”
Sadly, the updated guidelines don't consider the tricuspid valve regurgitation as a general consequence of left sided heart disease but again have the tendency to stress the importance of the awareness of tricuspid disease in patients with significant mitral valve disease following data acquired after mitral clip therapy. In contrast, recent literature demonstrates that even after TAVI tricuspid valve dysfunction is associated with significantly increased mortality. This underlines that left-sided heart disease in general is responsible for FTR (15).
Pathophysiologic Background
From a morphological standpoint FTR is known for its dynamic disease progression and can be divided into three phases (16):
1. Dilatation of the RV results in dilatation of the tricuspid annulus. At this stage TR might not even be present depending on the degree of annular dilatation and lack of leaflet coaptation.
2. Progressive dilatation of the RV and tricuspid annulus will lead to severe lack of coaptation resulting in significant TR.
3. RV dilatation especially in the region of the free wall will in addition to annular dilatation lead to tethering of the tricuspid leaflets, due to the attachment of the papillary muscles of the tricuspid leaflets to the free wall of the RV. A tethering height of more than 8 mm is reported to be predictive of more than moderate functional TR.
Surgical Approaches
According to these three phases, surgical repair of the tricuspid valve for functional TR requires tailored strategies.
In the first two stages, tricuspid annuloplasty alone gives excellent results. The third phase however necessitates treatment of the annular dilatation as well as the leaflet tethering since annuloplasty alone is unlikely to be successful in treating TR. Here two options come into play—a reconstructive approach or the replacement of the valve.
A variety of supplemental techniques for addressing leaflet tethering, such as anterior leaflet patch augmentation, double- orifice valve or bicuspidization repair, have demonstrated efficient and lasting results. Not least, these techniques provide the concept and justification for many proposed catheter-interventional approaches. Regarding the replacement of the valve, a potential recurrence of TR due to disease progression is prevented (16). However, life-long and rather aggressive anticoagulation therapy after mechanical valve implantation or the inevitable long-term valve degeneration following implantation of a biological prosthesis present significant drawbacks. With the arrival of interventional valve-in-valve technology, the choice for a biological prosthesis appears to be preferable.
Interventional Approaches
Transcatheter tricuspid valve intervention (TTVI) is at an early stage of introduction into practice and only a few hundred patients have been treated so far (17, 18). The first interventional valve replacement was very recently performed (19).
According to their mode of action tricuspid valve catheter devices can be divided into four groups (20):
• Tricuspid valve annuloplasty devices
• Tricuspid edge-to-edge technique
• Heterotopic caval valve devices
• Coaptation devices
Due to the nature of the disease progression, the majority of patients qualifying for interventional treatment are usually those with advanced disease (phase two to three). According to extensive research done on surgically treated patients, most of the above mentioned interventional devices will not be effective in treating the pathology. It is our strong opinion, that industry and doctors should concentrate on annuloplasty devices and devices replacing the tricuspid valve. It would be unwise to flood the market with devices not able to treat the most common pathology and by that depriving very sick patients from an effective therapy.
Conclusion
In conclusion, there is a clearly unmet need for the interventional treatment of TR mainly in very sick patients with FTR. Nonetheless device development and introduction must focus more on the mechanism of the disease in order to effectively treat it. The focus needs to be on annuloplasty devices and complete valve replacement strategies. One can only hope, that the current interest into interventional therapy of the tricuspid valve disease will bring back the “forgotten valve” into the conscience of the cardiological and surgical community. On the one hand, reminding cardiologists, that beside asymptomatic presentation of their patients a timely referral is mandatory for allowing a low-risk and optimal surgical intervention, on the other hand, reminding surgeons to address more consequently concomitant tricuspid valve disease and to apply repair strategies. The availability of interventional catheter-based techniques must not serve as an excuse for again “forgetting” the dysfunctional tricuspid valve and delaying therapy.
Author Contributions
DR: Idea and writing; ER: Correction and valuable Input; FS: Considerable Input; MP: Correction and Idea; AK: Discussion and Conclusion; LE: Final Correction; TC: Idea, Structuring, Correction.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg. (1987) 94:488–97.
2. Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. Guidelines on the management of Disease of the European Society of Cardiology. Eur Heart J. (2007) 28:230–268. doi: 10.1093/eurheartj/ehl428
3. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing Committee to Revise the 1998 Guidelines for the management of patients with Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation (2008) 118:e523–661. doi: 10.1161/CIRCULATIONAHA.108.190748
4. Nath J, Forster E, Heidenreich PA. Impact of tricuspid regurgitation on long term survival. J Am Coll Cardiol. (2004) 43:405–9. doi: 10.1016/j.jacc.2003.09.036
5. Dreyfus GD, Corbi PJ, Chan KMJ, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann Thorac Surg. (2005) 79:127–32. doi: 10.1016/j.athoracsur.2004.06.057
6. Dreyfus GD. Functional tricuspid pathology: to treat or not to treat? That is the question J Thorac Cardiovasc Surg. (2017) 154:123–4. doi: 10.1016/j.jtcvs.2017.03.015
7. Chikwe J, Itagaki S, Anyanwu A, Adams D. Impact of concomitant tricuspid annuloplasty on tricuspid regurgitation, right ventricular function, and pulmonary artery hypertension after repair of mitral valve prolapse. J Am Coll Cardiol. (2015) 65:1931–8. doi: 10.1016/j.jacc.2015.01.059
8. Dion RA. Is the air in Toronto, Rochester, and Cleveland different from that in Mondon, Monaco, Leiden, Genk, Milan, and New York? J Thorac Cardiovasc Surg. (2015) 150:1040–3. doi: 10.1016/j.jtcvs.2015.08.048
9. Rogers JH, Bolling SF. Surgical approach to functional tricuspid regurgitation: should we be more aggressive? Curr Opin Cardiol. (2014) 29:133–9. doi: 10.1097/HCO.0000000000000046
10. Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation (2005) 112(9 Suppl.):I453–7. doi: 10.1161/CIRCULATIONAHA.104.524421
11. Bendetto U, Melina G, Angeloni E, Refice S, Roscitano A, Comito C, et al. Prophylactic tricuspid annuloplasty in patients with dilated annulus undergoing mitral valve surgery. J Thorac Cardiovasc Surg. (2012) 143:632–8. doi: 10.1016/j.jtcvs.2011.12.006
12. Pozzoli A, Elisabetta L, Vicentini L, Alfieri O, De Bonis M. Surgical indication for functional tricuspid regurgitation at initial operation: judging from long term outcomes. Gen Thorac Cardiovasc Surg. (2016) 64:509–16. doi: 10.1007/s11748-016-0677-5
13. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. (2014) 148:e1–132. doi: 10.1016/j.jtcvs.2014.05.014
14. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. ESC/EACTS guidelines for the management of valvular heart disease: the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. (2017) 36:2739–91. doi: 10.1093/eurheartj/ehx391
15. Amat-Santos IJ, Castrodeza J, Nombela-Franco L, Muñoz-García AJ, Gutiérrez-Ibanes E, de la Torre Hernández JM, et al. Tricuspid but not mitral regurgitation determines mortality after TAVI in patients with nonsevere mitral regurgitation. Rev Esp Cardiol. (Engl Ed). (2017) 71:357–64. doi: 10.1016/j.rec.2017.08.019
16. Dreyfus GD, Martin RP, John Chan KM, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol. (2015) 65:2331–6. doi: 10.1016/j.jacc.2015.04.011
17. Rodés-Cabau J, Hahn RT, Latib A, Laule M, Lauten A, Maisano F, et al. Transcatheter therapies for treating tricuspid regurgitation. J Am Coll Cardiol. (2016) 67:1829–45. doi: 10.1016/j.jacc.2016.01.063
18. Latib A, Mangieri A. Transcatheter tricuspid valve repair: new valve, new opportunities, new challenges. J Am Coll Cardiol. (2017) 69:1807–10. doi: 10.1016/j.jacc.2017.02.016
19. Navia JL, Kapadia S, Elgharably H, Harb SC, Krishnaswamy A, Unai S, et al. Tricuspid annuloplasty ring.Circ Cardiovasc Interv. (2017) 10:e005840. doi: 10.1161/CIRCINTERVENTIONS.117.005840
Keywords: tricuspid valve insufficiency, interventional therapy, surgery, new devices, future strategy
Citation: Reineke DC, Roost E, Schoenhoff F, Pasic M, Kadner A, Englberger L and Carrel TP (2018) Transcatheter Treatment of Tricuspid Valve Disease: An Unmet Need? The Surgical Point of View. Front. Cardiovasc. Med. 5:98. doi: 10.3389/fcvm.2018.00098
Received: 19 April 2018; Accepted: 02 July 2018;
Published: 20 July 2018.
Edited by:
Maurizio Taramasso, UniversitätsSpital Zürich, SwitzerlandReviewed by:
Luigi Biasco, Cardiocentro Ticino, SwitzerlandBenedetto Del Forno, San Raffaele Hospital (IRCCS), Italy
Copyright © 2018 Reineke, Roost, Schoenhoff, Pasic, Kadner, Englberger and Carrel. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: David C. Reineke, david.reineke@insel.ch