Tricuspid Regurgitation – Valvular Heart Disease

00:01 So, let’s talk just for a few seconds about the final valve, the tricuspid valve. The tricuspid valve can be affected in severe rheumatic heart disease, but these days, that is very rarely seen. One can have congenital tricuspid stenosis, something that often requires repair in childhood. But, most commonly, we see tricuspid regurgitation when patients develop heart failure that results in dilatation and poor functioning of the right ventricle.

00:30 What happens then is the right ventricle stretches the valve ring a little bit so that it leaks and often, we call this functional tricuspid regurgitation. Why? Because it gets better when we treat the heart failure and the heart shrinks down a little bit.

00:47 Occasionally, when a patient is being sent for valve replacement, either mitral valve or aortic valve replacement, there is such severe heart failure that the tricuspid valve has been markedly stretched open and in that setting, either tricuspid valve replacement or more commonly, a plastic surgical operation in which the valve is tightened up is done by the surgeons at the same time that they replace either the mitral, aortic valve or possibly both.

01:16 In most cases, the functional a tricuspid regurgitation gets better when the patient’s heart failure is treated.

01:24 A new 2022 update recommends concomitant tricuspid valve surgery for patients with tricuspid annular dilation or prior right heart failure.

01:36 As this reduces the risk of progressive tricuspid regurgitation, the significance of tricuspid regurgitation is the high mortality that is seen when this is present, often late in heart failure and thus people often miss it and don't think about it.

01:52 and thus people often miss it and don't think about it.

01:54 Severe tricuspid regurgitation is an independent protector of mortality in these heart failure patients, even when their other cardiovascular conditions are apparent.

02:02 even when their other cardiovascular conditions are apparent.

02:05 For example, in patients with the mitral or aortic valve disease or any form of heart failure, newer transcatheter based therapies have shown early safety and efficacy in other words, clipping have shown early safety and efficacy in other words, clipping one of the leaflets to the other, one of the leaflets to the other, thereby closing the orifice for regurgitation transcatheter devices use either a clip on the valve leaflets as mentioned, or they can have an annual or remodeling device, something that goes into the annuals and tightens up the annulus.

02:37 And they've been approved for use in Europe and they're still under investigation here in the U.S.

02:42 These devices are probably going to be common in the future management of tricuspid regurgitation, particularly in patients with advanced heart failure.

02:52 Just an echo here to show you again, an example of severe tricuspid regurgitation, you can see there the rainbow image of a large jet of tricuspid regurgitation going down into the right ventricle in this patient with functional tricuspid regurge secondary to heart failure.

03:14 So, in conclusion, valvular heart disease is still with us. It’s still quite common, but there has been a major change in the form of valvular heart disease over the last four, five decades because of the aging population and because of the near eradication of rheumatic fever.

03:32 Most of the patients we see in the hospital these days have calcific atherosclerotic aortic stenosis and most of them are quite elderly.

03:41 We still see a fair number of people with mitral valve disease, but it’s usually again, congenital.

03:47 Patients with myxomatous or prolapsing mitral valve disease, that’s a congenital form. Usually, those patients do well with medical therapy and they don’t require a valve replacement or repair except when a portion of the valve tears, one of the cords tear and the patient has acute mitral regurgitation.

04:06 The elderly population with atherosclerotic aortic stenosis often have a lot of co-morbid conditions. Of course, theyre elderly and so, they may be quite complicated with lung disease and liver disease and so forth and they often represent a real challenge to the cardiologist. Fortunately, we are now able to replace the valve with a catheter procedure which is much less invasive compared to opening the chest and for many of these elderly and frail individuals, that’s a very good alternative.

04:36 The femoral artery is used for transcatheter approach to the aortic valve for implantation or replacement known either as to the eye or whatever we usually call it in my hospital.

04:48 Tabbara trans aortic valve replacement.

04:48 Tabbara trans aortic valve replacement.

04:52 The decision for transcatheter valve replacement is made by a multidisciplinary heart team, including the surgeons and the cardiologist, often anesthesia as well, and the pump teams in conjunction with the patient.

05:03 and the pump teams in conjunction with the patient.

05:05 And it's based on individualized risk benefit assessment, including estimated surgical risk versus estimated risk of complications.

05:13 Whether with a TAVI or tabbara.

05:14 Whether with a TAVI or tabbara.

05:15 In other words, patients in whom we think the surgical risk is going to be high In other words, patients in whom we think the surgical risk is going to be high are offered Tabbara patients usually younger patients are usually offered surgery with a more long lasting valve factors favoring transcatheter aortic valve replacement are, again, as mentioned, patients who in whom there's a relative contraindication to surgery.

05:36 The best example is older age and comorbid conditions.

05:39 The best example is older age and comorbid conditions.

05:41 And of course they have to have good femoral arteries in order to get the catheter.

05:46 This is fairly large catheter up with the valve deflated past across the the current stone article and the balloon is inflated and pushes the new tissue valve into place.

05:59 Keeping the aortic valve then functional.

06:00 Keeping the aortic valve then functional.

06:03 The various forms of mitral valve disease can come from a variety of sources. For example, endocarditis and a whole bunch of other conditions, but the commonest is the myxomatous one.

06:16 Mitral valve repair in these patients is preferred to mitral valve replacement except in very elderly individuals. Endocarditis is often a problem. Any injury to the valve makes that valve more susceptible to a bacterial infection and with the bacterial infection, you often have an acute leak, either acute aortic regurgitation or acute mitral regurgitation.

06:39 These patients need urgent surgery. Well, that takes us through the entire course of valve disease. As you can see, it’s quite complicated with a number of different lesions, but in the end, it’s aortic stenosis that is the most common these days.

06:56 Thanks very much for being with me today. I look forward to speaking with you in the