Contemporary Reviews in Interventional Cardiology

Contemporary Reviews in Interventional Cardiology
Interventional Cardiology Perspective of Functional
Tricuspid Regurgitation
Shikhar Agarwal, MD, MPH; E. Murat Tuzcu, MD; E. Rene Rodriguez, MD; Carmela D. Tan, MD;
L. Leonordo Rodriguez, MD; Samir R. Kapadia, MD
A
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vast unmet need exists for tricuspid valve (TV) repair
for functional tricuspid regurgitation (FTR) among patients undergoing left heart valve surgery. The FTR is a
dynamic entity that is governed by several pathophysiologic
mechanisms like TV annular dilatation, annular shape, pulmonary hypertension, left or right ventricle dysfunction, right
ventricle geometry, and leaflet tethering. Treatment options
for FTR are primarily surgical. No clear medical management
exists for treatment of FTR. Several studies have demonstrated improvement in functional status along with tricuspid
regurgitation grades among individuals undergoing concomitant TV repair as compared with those undergoing only left
heart valve surgery, although data on mortality benefits are
equivocal. Percutaneous TV technology may be initially
useful for patients with FTR who are at high risk for
open-heart surgery. Once the other percutaneous technologies
for mitral, aortic, or pulmonary valve become widely available, the need for percutaneous TV procedures will be even
more apparent. Initial data from animal studies have shown
encouraging results. A concurrent effort is being invested to
develop effective mechanistic models, right stent materials,
superior valve devices along with a precise technology for
valve deployment.
The current prevalence of moderate-to-severe tricuspid
regurgitation (TR) is estimated to be 1.6 million in the United
States.1 Of these, only ⬇8000 patients undergo tricuspid
valve (TV) surgeries annually, most of them in conjunction
with left heart valve surgeries (LHVSs).1 This has resulted in
a vast unmet need of recognizing and effectively treating TR
in adult populations. With the decline of rheumatic heart
disease, a large proportion of the TR encountered is functional rather than organic. Functional TR (FTR) refers to the
TR secondary to the left heart pathology or right heart
pathology in the face of a normal TV leaflet morphology.
to be used for the detection of TR. Concomitantly, advances
in the echocardiographic technology prompted the use of 2D
surface echocardiography to be used in preoperative characterization of TR. Currently, 2D echocardiography in conjunction with Doppler color flow mapping forms the mainstay of
TR detection and characterization. Methods of TR detection
are presented in Table 1, Figures 1 through 3, and movie clips
1 and 2.
Early in 1965, it was reported that successful mitral valve
replacement (MVR) in patients with pulmonary hypertension
led to a prompt reduction in pulmonary artery pressures.9 In
serial studies, however, it was discovered that this reduction
might be “gradual” rather than a “prompt” one, occurring
over a period of months. Subsequently, Cohen et al10 reported
that the changes in pulmonary hemodynamics after MVR
might actually be insignificant and unpredictable.
TR is a frequent problem among patients with valvular
disease. In a large retrospective cohort of 5223 patients
undergoing echocardiography, Nath et al11 reported that 819
patients (15.6%) demonstrated evidence of moderate-tosevere TR. Dreyfus et al12 observed that up to 48% of the
patients with chronic severe mitral regurgitation undergoing
MV repair had tricuspid annular diameter greater than twice
the normal size (ⱖ70 mm) regardless of the TR grade.
Despite the high prevalence of FTR among patients with left
heart valve pathologies and a direct implication of FTR
correction on long-term outcomes, the proportion of patients
undergoing TV repair remains extremely variable.
Anatomy of the TV
TV Orifice and Annulus
In anatomic position, the TV lies at an angle of 45 degrees
with the sagittal plane with an inclination such that it faces
somewhat inferiorly and anterolaterally to the left side. The
normal TV annulus is an elliptical, nonplanar structure with a
distinct bimodal or saddle-shaped pattern having 2 high
points (oriented toward the right atrium) and 2 inferior points
(oriented toward the RV).13 The nonplanar and noncircular
Historical Perspectives
The methods of detecting TR have evolved considerably over
the years. The initial methods included intraoperative digital
exploration with qualitative right atrium and right ventricle
(RV) assessment. In the 1980s, right heart angiography began
From the Departments of Internal Medicine (S.A.), Pathology (E.R.R., C.D.T.), and Cardiovascular Medicine (L.L.R.), Cleveland Clinic, Sones Cardiac
Catheterization Laboratories (E.M.T., S.R.K.), Cleveland Clinic, Cleveland, Ohio.
The online-only Data Supplement is available at http://circinterventions.ahajournals.org/cgi/content/full/2/6/565/CIRCINTERVENTIONS.
109.878983/DC1.
Correspondence to Samir Kapadia, MD, Sones Cardiac Catheterization Laboratories, Cleveland Clinic, Desk J2-4, Cleveland, OH 44195. E-mail
[email protected]
(Circ Cardiovasc Interv. 2009;2:565-573.)
© 2009 American Heart Association, Inc.
Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org
565
DOI: 10.1161/CIRCINTERVENTIONS.109.878983
566
Table 1.
Circ Cardiovasc Interv
December 2009
Methods for Detection of Tricuspid Regurgitation
Classification/Comments
Reference
Intraoperative digital assessment
Method
Initial method of assessment coupled with qualitative assessment of RA and RV
2
Right-sided ventriculography (Figure 1)
Grade 0: Absence of TR: No opacification or “puffs” of contrast medium in RA
Grade I: Mild TR: Incomplete/transient RA opacification including early systolic
jet-like regurgitations
Grade II: Moderate TR: Complete and persistent RA opacification
2D echocardiography with color Doppler mapping
Grade III: Severe TR: Opacification of vena cavae in addition to RA cavity
3
Based on distance reached by regurgitant jet
4
1⫹: ⬍1.5 cm
2⫹: 1.5 to 3.0 cm
3⫹: 3.0 to 4.5 cm
4⫹: ⬎4.5 cm
Based on area covered by regurgitant jet
4
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1⫹: ⬍2 cm2
2⫹: 2.0 to 4.0 cm2
3⫹: 4.0 to 10.0 cm2
4⫹: ⬎10.0 cm2
VCW
5
VCW ⱖ6.5 mm identifies severe TR with 89% sensitivity and 93% specificity
Contrast-enhanced multidetector CT (Figure 2)
Presence of TR is indirectly indicated by premature opacification of hepatic
veins or IV during first-pass intravenous contrast enhancement
6
Cine nuclear magnetic resonance
Comparison of NMR angiography demonstrated sensitivity of 88% and
specificity of 94% in accurately classifying TR
7
3D echocardiography (Figure 3, movie clips 1 and 2)
Accurate geometric classification including tenting volume and annular
characteristics are well characterized
8
VCW indicates vena contracta width.
nature of the TV has major mechanistic and therapeutic
implications for TV repair (Figures 4 through 7).
The “fibrous skeleton of the heart” provides a stable but
deformable platform for attachment of the fibrous core of the
TV. Two pairs of collagenous prongs (fila cornaria) extend
from the central fibrous body toward the left (forming the
mitral annulus) and the right (forming the tricuspid annulus).
Although the fila are more continuous near their origin, they
vary greatly at peripheral points. At several peripheral sites,
only fibroadipose tissue separates the right atrium and RV.
Because of a lower proportion fibrous tissue and a comparatively larger size, the TV annulus is considered less robust
than the MV annulus.14 Unlike MV, the TV annulus does not
contract. Systolic dysfunction of the periannular myocardium
may impact the TV annulus, resulting in TV dysfunction.
Leaflets and Commissures
The TV consists of 3 leaflets of unequal sizes: anterosuperior,
posterior, and septal leaflets. The largest leaflet, the anterosuperior leaflet, hangs like a curtain between the inlet and
outlet part of RV. It spans the aortic valve groove extending
from the posterolateral aspect of the supraventricular crest
(anteroinferior commissure) along its septal limb to the
membranous septum, terminating at the anterosuperior commissure. The attachment of the septal leaflet extends from the
inferoseptal commissure on the posterior ventricular wall
Figure 1. Right atrial angiogram to demonstrate relations of the TV on fluoroscopy. Left,
Frame from the AP projection of the RV in systole. The TV is in closed position. Right, Lateral
projection with RV in diastole and TV in open
position.
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Figure 2. Computed tomography images demonstrating the TV relation to the aorta and pulmonary artery.
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across the muscular septum and then spans across the
membranous septum to terminate at the anteroseptal commissure. The septal cusp defines 1 of the borders of the Triangle
of Koch, the apex of which marks the location of the aortic
valve node. The posterior leaflet is less constant than the
other 2 and is completely mural in its attachment, extending
from the inferoseptal commissure to the anteroinferior commissure (Figure 5).
Papillary Muscles
The leaflets are supported by papillary muscles of uneven
sizes. The anterior papillary muscle (Figure 4) is the largest
and arises from the anterolateral ventricular wall below the
anteroinferior commissure. The medial papillary muscle is
small yet typical and arises from the posterior limb of
septomarginal trabecula. The bifid or trifid inferior papillary
muscle is often inconstant and arises from the myocardium
below the inferoseptal commissure. In addition, there is often
presence of several smaller, highly variable muscles attaching
the cuspal margins to the right ventricular wall. All papillary
muscles send chordae to tether the respective valve leaflets.
One of the characteristic differences between the RV and LV
is the presence of chordae in the RV extending from the septal
leaflet to the ventricular septum; such septal insertions are
conspicuously absent in the LV.
Pathophysiology
TV closure is a dynamic and complex function that requires the
coordinated function of valve leaflets, chordae, papillary mus-
cles, TV annulus, and periannular myocardium along with
optimal functioning of the RV. Several factors have been
implicated in the development and progression of TR (Table 2).
Treatment
Several surgical options exist for treatment of FTR with
normal leaflets and chordal structures. Techniques for correction of mild to moderate TR include plication of the posterior
leaflet’s annulus (bicuspidization) and partial purse-string
reduction of the anterior and posterior leaflet annulus (De
Vega style techniques). A significant degree of FTR may
require correction using rigid or flexible rings or bands placed
to reduce the annular size and achieve leaflet coaptation. The
majority of current surgical techniques center around reduction of a large TV annular size in correction of FTR.
However, this fails to adequately address the important role
of persistent leaflet tethering in the genesis of FTR.
TV replacement is mostly reserved for advanced disease
arising due to structural abnormality of valve leaflets. It has been
reported that TV replacement carries a much higher risk of
mortality as compared with TV annuloplasty (TVA) for correction of TV anomalies.26 Medical treatment for FTR focuses on
improving the underlying cause, whenever possible, and to
mitigate its impact on the body. Different treatments strategies
including conservative management can be studied in a systematic manner using end points of efficacy of TR reduction,
mortality, functional status, and recurrence of TR.
Figure 3. Three-dimensional echocardiogram demonstrating the motion of the TV. Complete opening (A), partial closure (B), and (C)
complete closure of the valve leaflets (B).
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Figure 4. Anatomy of the TV and the valvular apparatus. The
anterolateral wall of RV and right atrium is removed to demonstrate the TV attachment to the ventricle. The relation of tricuspid annulus to the right coronary artery is visualized. Interatrial
septal relations with superior vena cava, IVC, and coronary
sinus are clearly visualized.
Reduction in TR Grade
Several studies have reported the persistence of TR in
patients undergoing LHVS alone without concomitant TV
procedure. Tager et al27 reported that in their experience, the
TV repair led to resolution of TR in 85% of patients with
preoperative TR, as compared with no resolution among
patients who were conservatively managed. Duran et al2
reported that postoperative TR was detectable in 18% of
patients undergoing TV repair with LHVS compared with
53% of patients in whom TR was “ignored.” Dreyfus et al12
have reported that the TR grade increased by 1.4⫾1.1 in
patients undergoing MVR alone, as compared with a fall of
0.5⫾0.9 among patients undergoing TVA with MVR
(P⬍0.001). Sagie et al17 reported that the progress of TR
(defined as increase in TR grade by ⬎2 grades) was encountered in 30% of individuals undergoing LHVS alone, which
was significantly higher than the 12.9% among the LHVS
done in conjunction with TVA. Interestingly, the preoperative
prevalence of moderate-to-severe TR among patients undergoing LHVS with TVA was 81% as compared with 0 patients
with moderate-to-severe TR among patients undergoing
LHVS alone. Czer et al28 reported that TVA provided
significant (ⱖ2⫹) reduction in regurgitation severity in 94%,
as compared with 14% among patients undergoing MVR
alone without concomitant TV procedure. Five-year
follow-up from another comparative study of patients with
LHVS with TVA versus LHVS alone found that concomitant
TVA may cause mild TV stenosis but produces sustained
preventive effects against TR. The TR jet area on long-term
follow-up was found to be 5.1⫾3.5 cm2 among the conservatively managed group as compared with 2.0⫾1.6 cm2
among the TVA group even though TR was significantly
milder preoperatively in the former group.29
Mortality and Functional Status
Concomitant correction of TR with LHVS yielded in-hospital
mortality of 8.9% and a 10-year survival of 78⫾3%.30 Even in
Figure 5. Cranial View of the same specimen as in Figure 4.
Three leaflets of TV are seen with their typical attachment.
cases of triple valve surgery, 1-year survival rates of 80⫾7%,
5-year survival rate of 75⫾8%, and 10-year survival rates of
41⫾15% have been reported.31 Improvement in surgical techniques reduced operative mortality for TV interventions with
LHVS considerably. In a large follow-up study (1974 –2003),
overall 30-day mortality rates were 18.8% for the entire duration
and 11.1% for a more recent period of 2000 –2003.26
In the experience of Dreyfus et al,12 where patients
undergoing MVR had a thorough evaluation of the TV, TVA
was performed if TV annular diameter was found to be twice
the normal size (ⱖ70 mm) regardless of the TR grade. No
significant difference in short- or long-term mortality rates
was observed. However, significant differences were observed in the postoperative symptomatic status of these
patients. On long-term follow-up, 14.1% of the patients
undergoing MVR alone had New York Heart Association
class 3 to 4 symptoms as compared with none of the patients
undergoing TVA with MVR remaining in New York Heart
Association class 3 to 4. Another surgical group also reported
that surgical correction of TR results in better functional
outcome but does not affect early and late survival.22
TR on Follow-Up
As mentioned earlier, residual TR is not an uncommon
phenomenon after TV surgery. It is even more frequent
among patients in whom the TR is “ignored” at the time of
LHVS. Among the patients undergoing LHVS with TVA,
22.4% of cases have been reported to have moderate-tosevere residual TR in the immediate postoperative period.32
On long-term follow-up, the prevalence of residual TR may
increase to as high as 31%.33 Czer et al28 have clearly
indicated that residual TR detected in the immediate postoperative period either persists or deteriorates over long-term
follow-up but rarely improves. A high proportion of individuals with residual TR may be in advanced stages of heart
failure on long-term follow-up. McCarthy et al33 reported that
up to 24% of the patients undergoing TV procedures were in
New York Heart Association class 3 to 4 after 4 years of
follow-up. Despite the high rate of heart failure among these
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Figure 6. Relation of TV to aorta and moderator band. The heart is dissected such that the cephalad portion of the atrium and right
ventricular outflow tract are shown in left side panel and the more caudal half is in the right panel. Attachments of tricuspid leaflets are
seen in relation to the aorta, the crista supraventricularis, and the pulmonary artery.
individuals, the rate of reoperation was merely 2.9% at 10
years, primarily because of avoidance of repeat surgeries in
these patients with poor midterm survival.33 In addition, late
TR occurring post-MVR requiring reoperation for correction
of significant TR has an extremely high mortality rates and
hence accurate detection and correction of TR at the time of
initial surgery is the most effective means of preventing the
occurrence of FTR.32
Lessons Learned From Percutaneous
Mitral Valvuloplasty
Percutaneous mitral valvuloplasty (PMV) for mitral stenosis
presents a unique model to assess the impact of correction of
left-sided valvular disease on progression of TR. The persistence of FTR after PMV contributes to increased morbidity
and mortality despite adequate percutaneous MV intervention.34 Song et al34 compared the outcome of patients with
mitral stenosis along with severe TR undergoing PMV to
those undergoing MVR with TVA. Although significant
improvement in the TR grade was observed among the latter
group, no significant differences in the estimated long-term
actuarial survival rates could be discerned. In Sagie’s experience,35,36 no correlation existed between the success of the
procedure and resolution of the TR.36 One of the major
reasons for this failure could be the lack of significant
reduction in TV annular diameter due to long standing TV
disease leading to irreversible changes in the TV annulus.37
This implies that to ascertain success in treatment of FTR, the
TV requires intervention.
Percutaneous TV Technology
Need for a Percutaneous Approach
Figure 7. Relationship between the septal leaflet of the TV, noncoronary cusp of the aortic valve, the membranous septum, and
the interatrial septum. The picture is taken from the posterior
aspect of the heart.
There is an unmet need for TV correction among patients
undergoing surgery for other valvular abnormalities. There
has been considerable development in percutaneous technologies for the MV, and a significant proportion of patients with
MV abnormalities have concurrent TV abnormalities that
need to be corrected. It is noteworthy that a high proportion
of patients with mitral regurgitation and coexisting TR have
poor functional status that increases their operative risk,
sometimes to unacceptably high levels. Percutaneous procedures may be an attractive alternative for patients deemed to
be high-risk surgical candidates. As mentioned earlier, PMV
may not relieve FTR, and uncorrected TR typically worsens
over time leading to poor symptomatic relief. In addition,
severe TR is a relative contraindication for PMV because the
outcomes of these patients are not optimal.38 Further, late
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Table 2.
December 2009
Angiographic and Pathophysiologic Correlates of Functional Tricuspid Regurgitation
Characteristic
TR grade
Comments and Controversies
References
Severity of preoperative TR implies increased odds of TV repair failure and residual TR
15, 16
Diastolic TVAD significantly predicts TR severity
17
Preoperative fractional shortening of TVAD predicts postoperative clinical/echocardiographic
deterioration
18
Planarity of annulus (due to lower annular heights) correlates with FTR
8, 13, 19
Circularity of annulus due to TV annular dilatation is encountered in patients with significant FTR
20
TV tethering/papillary muscle
dysfunction
Tethering height and tethering area have emerged as significant correlates of FTR
15, 20, 21
Septal leaflet tethering is most prominent among patients with severe FTR
20
Pulmonary hypertension
High pulmonary artery systolic pressures have been found to be an independent predictor of
FTR severity
20
Postoperative residual TR is predicted by level of preoperative pulmonary resistance
2
The only “incremental factor” for late cardiac mortality post MVR is pulmonary hypertension
22
“RV hypokinesia” indicates reduced sphincteric action of TV annulus and may predict
postoperative outcomes
23
RV systolic area is significantly predicts TVAD and TV tethering height
21
RV eccentricity index and RV sphericity index depict strong correlation with TR orifice area and
TR severity
21, 24
Atrial fibrillation/atrial size
Increasing LA and RA sizes along with presence of preoperative atrial fibrillation predicts FTR
progression postoperatively
25
LV dysfunction
Early postoperative LVEF is independent predictor of late occurrence of TR
15
TV annular characteristics
TVAD
TV annular shape
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RV characteristics
RV dysfunction
RV shape
TVAD indicates TV annular diameter.
operation or reoperation for correction of significant FTR
after a prior MV procedure is associated with a high morbidity and mortality; hence, availability of a percutaneous
treatment option would allow patients to have both procedures in a minimally invasive fashion possibly leading to
more favorable outcomes.
Percutaneous TV Repair and
Replacement Technologies
It remains to be seen whether percutaneous repair or replacement of the TV becomes a reality (Figure 8). Edge-to-edge
repair, coronary sinus-related approaches, and ventricular
remodeling concepts that are available for mitral valve repair
are unlikely to work in the TV because of obvious anatomic
differences. However, there are several concepts that were
constructed for the treatment of mitral regurgitation, which
might be applicable to TR correction as well (Figure 8).
These include direct annular plication (CORDIS), the application of radiofrequency (Quantumcor), and the regurgitant
orifice spacer/occluder concept.39 – 43 The direct annular plication is achieved by placing the clips on the annulus for
plication. With the Quantumcor device, radiofrequency is
applied to the annulus and induces scarring, resulting in
shrinking of the annulus. The spacer/occluder technology
places a device in the valve orifice over which the leaflets
coapt and prevent regurgitation. GDSAccucinch is another
technology that may be harvested for TV. This involves
placement of anchors at select sites around the MV annulus,
followed by increasing traction on the cable to reduce
interanchor distance, thereby reducing the MV annular size.40
Although conceptually exciting, there is still no data from
animal experiments in which these technologies have been
used.
Boudjemline et al14 published one of the first studies with
percutaneous TV implantation in healthy ewes. The authors
used a percutaneously inserted valved stent with a nitinol
cylinder separating 2 large disks with sealing achieved by a
polytetrafluoroethylene membrane. In their experience, 7 of
the 8 devices were successfully deployed in the desired
location; 1 stent was caught up in tricuspid chordae leading to
incorrect deployment; and severe paravalvular leak with
instantaneous death. Among the 4 animals euthanized after
1-month postimplantation, 1 demonstrated a significant paravalvular leak. There was a significant pericardial effusion,
and the polytetrafluoroethylene membrane was found to be
torn beside a weld fracture. Zegdi et al44 report that their
experience in a sheep model with a valve stent device
consisting of a porcine stentless valve mounted in a 30-mm
nitinol stent device. The stent consisted of 2 sutures encircling the stent at either end whose traction through a proximal
handle could affect the deployed versus compressed state of
the stent. This mechanism allowed precise control, and if
needed, it could reverse the deployment of the valved stent.44
The other proposed approach for percutaneous TV repair is
the implantation of separate valves in the superior vena cava
and inferior vena cava (IVC) to prevent damage to the liver
and other organs due to high right-sided pressures.45 Percutaneous IVC valve implantation was carried out at our
institution for correction of severe TR causing severe liver
congestion and ascites in a high-risk patient with radiation
heart disease. Despite the correction of only IVC backflow,
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Figure 8. Concepts for percutaneous correction of FTR. A, Dissected
heart with valved stent devices in the superior and inferior vena cava
(black arrows); the spacer/occluder (white arrow) extends from the
right ventricular apex to the tricuspid annular plane to facilitate an optimal coaptation of the valve leaflets. B, Appearance of the TV after
millipede annuloplasty. C, Valve annulus after plication annuloplasty.
D, Valved stent device deployed in the tricuspid position.
the patient reportedly tolerated the procedure well with a
good postoperative outcome (personal communication). This
patient experience is unique because the valve was designed
such that the anchor elements were separate from the annulus,
which accommodates the changes in venous size without
causing valve dysfunction. Corno et al46 demonstrated a
relatively quick deployment of a glutaraldehyde-preserved
valved bovine jugular xenograft mounted in a nitinol Z stent
in 5 adult pigs positioned at target level between hepatic veins
and cavoatrial junction; mean duration of deployment being 8
minutes. The in vitro and in vivo experiments confirmed the
feasibility of implantation of a self-expanding valved stent in
IVC, the accuracy of which was significantly improved by
intravascular ultrasound.46
IVC morphology with coexistent TR has not been extensively characterized. Capomolla et al47 looked at IVC diameter in 100 patients with congestive heart failure including 34
patients with TR. Mean (SD) maximum IVC diameter was
found to be 15⫾6.3 mm, and mean (SD) minimum IVC
diameter was found to be 10⫾9.7 mm. The diameters suggest
that the IVC may be amenable to stent valve placement but
the technical details of deployment along with the long-term
effects of high right atrium pressures need to be studied
further.
Challenges for Percutaneous TV Replacement
The large diameter of the tricuspid annulus, relatively illdefined anatomic fibrous structure of the annulus, slow flow,
and trabeculated structure of the RV pose significant challenges for the development of percutaneously deployable TV.
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The TV annulus is typically twice the normal size ie,
⬎70 mm of diameter in patients with significant FTR. It is
indeed challenging to design an expandable valve of 70 mm
that could be easily deployed through the femoral vein using
standard sheaths and delivery catheters. Once deployed, it is
necessary that the valve be securely anchored into its location
to prevent paravalvular leaks, and more importantly, embolization. Trapping of the device in the chordae may be another
issue.14 Exuberant tissue overgrowth along with nodular
calcifications has been noted in the TV area compared with
the MV area. This has been attributed to lower blood pressure
and velocity that favor thrombi deposits in the biological
valve implanted in the tricuspid position.48,49 Other challenges of percutaneous valves including stent fracture, inaccurate imaging and positioning, and paravalvular leak are
relevant in percutaneous TV implantation. Access would be
an important consideration due to angulation of the annulus in
relation to the superior vena cava and IVC. RV access may be
considered but is less robust than the LV apical approach for
aortic valve due to the thin wall of the ventricle and multiple
chordae.
The durability of stent material is a major consideration
owing to the large size and motion of the annulus. Although
balloon-expandable frames remain as options, self-expanding
stents with some anchoring mechanism are preferable due to
anatomic considerations. The durability of the valve is
another concern due to lower pressure and a slower flow
circuit. Rapid advancements in tissue valve engineering may
help to solve some of these issues.
Conclusion
A vast unmet need of TV repair for FTR exists in patients
undergoing LHVS. FTR is a dynamic entity that is governed
by several factors including TV annular dilatation, TV
annular shape, pulmonary hypertension, LV/RV dysfunction,
RV geometry, and leaflet tethering. Several studies demonstrate improvement in functional status along with TR grades
among individuals undergoing concomitant TV repair, in
comparison with those undergoing LHVS alone, although
data on mortality benefits are equivocal.
Percutaneous TV technology may be useful for patients
with FTR who are at high risk for open-heart surgery. Data
from initial animal studies about the feasibility of implantation and efficacy of the percutaneous TV are encouraging. Once the other percutaneous technologies for mitral,
aortic, or pulmonary valve become widely available, the
need for percutaneous TV procedures will be even more
apparent.
Acknowledgments
We thank Marion Tomasko and Kathryn Brock for assistance in
preparation of the manuscript.
Disclosures
None.
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KEY WORDS: valves 䡲 tricuspid regurgitation 䡲 functional tricuspid
regurgitation 䡲 percutaneous valves 䡲 tricuspid repair
Downloaded from http://circinterventions.ahajournals.org/ by guest on November 18, 2016
Interventional Cardiology Perspective of Functional Tricuspid Regurgitation
Shikhar Agarwal, E. Murat Tuzcu, E. Rene Rodriguez, Carmela D. Tan, L. Leonordo Rodriguez
and Samir R. Kapadia
Downloaded from http://circinterventions.ahajournals.org/ by guest on November 18, 2016
Circ Cardiovasc Interv. 2009;2:565-573
doi: 10.1161/CIRCINTERVENTIONS.109.878983
Circulation: Cardiovascular Interventions is published by the American Heart Association, 7272 Greenville
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Correction
In the article by Agarwal et al, “Interventional Cardiology Perspective of Functional Tricuspid
Regurgitation,” which appeared in the December 2009 issue of the journal (Circ Cardiovasc
Interv. 2009;2:565–573), an error in the author listing occurred:
Carmela D. Tan, MD should be listed as an author.
Shikhar Agarwal, MD, MPH; E. Murat Tuzcu, MD; E. Rene Rodriguez, MD; Carmela D. Tan,
MD; L. Leonordo Rodriguez, MD; Samir R. Kapadia, MD
Dr Tan is from Cleveland Clinic, Cleveland, OH.
These errors have been corrected in the current online version of the article (http://
circinterventions.ahajournals.org/cgi/content/full/2/6/565). The authors regret the error.
DOI: 10.1161/HCV.0b013e3181d6bb44
(Circ Cardiovasc Interv. 2010;3:e1.)
© 2010 American Heart Association, Inc.
Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org
e1
SUPPLEMENTAL MARTERIAL
Movie Clip Descriptions
These video clips represent real-time 3 dimensional echocardiograms of the tricuspid valve.
After obtaining the reference apical 4-chamber and 2-chamber views, full-volume datasets of
tricuspid valve are visualized. As shown in movie 1, four conical subvolumes are first obtained.
After the acquisition of subvolumes, these are automatically integrated to create a pyramidal
volumetric representation of the tricuspid valve (movie 2). All three leaflets of the valve are
clearly visualized in these 3-D images, as seen from the right ventricle. This technique is
invaluable in assessment of functional tricuspid regurgitation as well as structural valvular
pathology.
CIRCULATIONAHA/2009/878983/R
1