Overview of Tricuspid Valve Repair
Tricuspid regurgitation, a condition where the heart’s tricuspid valve doesn’t close tightly and causes blood to flow backwards, is a common reason why people might need a tricuspid valve repair. In the United States, about 1.6 million people have moderate to severe tricuspid regurgitation, but only a few thousand have the valve repair procedure each year.
Records show that over a decade, around 5,005 primary tricuspid valve procedures were performed, with 8.8% of patients passing away while in the hospital. Since recent studies have shown that not treating severe tricuspid regurgitation can lead to worse outcomes, more people are becoming interested in treating these valve issues. The studies also found that tricuspid regurgitation is often seen in patients who have issues with heart failure.
Fixing the tricuspid valve is more complicated than fixing the mitral valve because of the complicated structure of the tricuspid valve. It has three flaps (leaflets), an intricate structure, and a complex part beneath the valve. This complexity makes the repair more challenging. Also, sometimes patients come to the doctor late, which can complicate the treatment and lead to worse outcomes.
Tricuspid regurgitation is also often seen in patients who have to have surgery on their mitral valve for another heart condition. Most experts agree that if a patient has severe tricuspid regurgitation, it should be addressed during the initial surgery, as later surgeries can carry a high risk of death around the time of the operation.
How to manage less severe forms of tricuspid regurgitation is still a topic of discussion. However, if left untreated during heart surgery, mild to moderate tricuspid regurgitation can get worse in about 25% of patients, potentially leading to a lower chance of survival and worse outcomes.
There is also debate about how to treat less severe tricuspid regurgitation during heart surgery. While some studies suggest that repairing the tricuspid valve in patients with moderate or less-than-moderate regurgitation may reduce the disease’s progression and improve outcomes, not all patients experience worsening of the condition. So, the way this condition is managed can vary widely.
Traditionally, most patients with significant tricuspid regurgitation are treated with drugs. Surgical intervention is often linked to high rates of complications and death in the hospital, particularly for advanced cases of right-sided heart failure or patients with prior left-sided heart surgeries. So, less invasive options are needed to treat tricuspid regurgitation more effectively.
In recent years, several devices have been developed to repair the tricuspid valve without invasive surgery, with the most common being the transcatheter tricuspid edge-to-edge repair (T-TEER). The TriClip (made by Abbott) is the first and most widely used T-TEER device. However, evidence for its safety and effectiveness primarily comes from retrospective studies that include real-world, unselected patient populations, or data collected from well-selected groups in prospective trials. As a result, transcatheter therapies for tricuspid regurgitation are becoming more common and are increasingly becoming a standard part of clinical care.
Anatomy and Physiology of Tricuspid Valve Repair
The human heart has four valves, and the largest of these is the tricuspid valve. It finds its place between the right atrium and right ventricle of the heart. Just as the name suggests, the tricuspid valve has three leaf-shaped parts: septal, anterior, and posterior. This valve, along with its surrounding structures, plays an important role in controlling the flow of blood. Additionally, it operates under lower pressure compared to other parts of the heart, allowing blood to flow through it quickly.
The three leaf-shaped parts of the tricuspid valve each have unique characteristics. The largest and most mobile is the anterior leaflet. Then we have the septal leaflet, which does not move much and is found close to a similar structure in the neighboring mitral valve. If this septal leaflet is attached to the wall of the right ventricle, it can lead to a condition known as Ebstein anomaly. Lastly, the posterior leaflet is the smallest, based on its circumference.
Usually, there are two additional supporting muscles, the anterior and posterior papillary muscles. Occasionally, there might be a third muscle present. These muscles help hold the three leaflets in place. Lastly, the tricuspid valve is encircled by a dynamic, D-shaped structure known as the annulus which changes shape and size as the heart beats.
There are two main types of problems that can affect your tricuspid valve, causing a condition called tricuspid regurgitation. Primary tricuspid regurgitation is when there’s a physical change in the valve’s structures and it can happen due to a variety of reasons, straight from birth (congenital) like Ebstein anomaly or double orifice valve, or acquired over time like due to a rare hormonal condition called carcinoid syndrome, infection of the valve, or trauma to the chest.
The second type, secondary tricuspid regurgitation, is more common and is usually caused by changes in dimensions of the right-sided chambers of the heart, rather than the valve itself. This type of regurgitation can occur due to diseases of the left side of the heart, high blood pressure in the lungs, or enlargement of the right atrium, among others.
Why do People Need Tricuspid Valve Repair
The American College of Cardiology and the American Heart Association suggest that tricuspid valve surgery, a procedure on one of the heart valves, should be performed during procedures involving other heart valves. This guideline is particularly important in cases where patients are showing symptoms of heart disease on the right side of the heart. The guidelines also suggest that even if patients not showing symptoms, but the right side of the heart appears to be weakening, an intervention might be needed.
However, in real-world scenarios, many patients end up undergoing treatment later in their disease progression. The ideal time to treat severe tricuspid regurgitation, a condition where the tricuspid valve doesn’t close properly, causing blood to flow backward, isn’t entirely clear. Nonetheless, the most recent guidelines emphasize the need to treat it before causing significant right-side heart dysfunction.
While tricuspid valve abnormalities can lead to health issues and even life-threatening conditions, standalone tricuspid valve repairs are rare. Most frequently, these repairs take place during other primary heart surgeries, especially for patients experiencing severe primary tricuspid regurgitation, a condition where the tricuspid valve can’t stop blood from flowing backward.
There are various scenarios where tricuspid valve repair or replacement may be needed. Some of these include cases with severe tricuspid regurgitation or stenosis, where the valve aren’t functioning properly; patients showing symptoms related to these conditions; patients undergoing other heart valve surgeries; or those with other specific conditions affecting the tricuspid valve.
One way to detect tricuspid valve regurgitation is through a unique high-pitched heart murmur, which can be heard using a stethoscope. Other potential symptoms may include physical weakness, a noticeable pulse in the neck or near the liver, or swelling in the abdomen, legs, or neck veins.
A research study explored a method of assessing the severity of tricuspid regurgitation, proposing that severe conditions could be identified by examining certain characteristics related to blood flow in the heart and its surrounding vessels. The parameters used correlate well with expert evaluations and magnetic resonance imaging (MRI) measurements, improving the consistency among the observers.
How is Tricuspid Valve Repair performed
Tricuspid valve repair is a surgical procedure often performed because of something called “tricuspid regurgitation”. This is a condition where the tricuspid valve, which is one of the four valves in your heart, doesn’t close properly, causing blood to flow backwards. The most common patients needing this repair have what we call “secondary (functional)” tricuspid regurgitation. Patients with a different form, known as “primary tricuspid regurgitation” where the damage involves multiple parts of the tricuspid valve, usually undergo valve replacement instead of repair.
The goal of tricuspid valve repair is to decrease the diameter of the valve and reduce the load on the right ventricle of your heart, which is the part that pumps the blood out to your lungs to get oxygen. By doing this, it can help increase the efficiency of the heart. Because of the position of the tricuspid valve in the heart, the surgeon must be mindful of several neighboring structures during the surgery.
There are several techniques available for the surgeon to repair the tricuspid valve:
- Suture annuloplasty: This refers to stitching techniques that reshape the valve. One method involves stitching around the valve to reduce its size, while another method reforms the valve into a two-flap valve by closing off a section of it.
- Ring annuloplasty: This technique uses a rigid or semi-rigid ring to reinforce the valve and keep it in the right shape. The size of the ring used is determined by the size of the patient’s ventricle.
- Clover technique: Like it sounds, this technique gives the valve a clover shape. Here, stitches are placed in the middle of the valve flaps and combined with ring annuloplasty to shrink the valve size.
- Other surgical techniques: These only apply to patients with primary tricuspid regurgitation, and vary depending on the specific situation of each patient, some of which involve repairing the muscular support structures of the valve.
Nonetheless, if your valve has been severely affected and the repair techniques are not suitable, your doctor might recommend valve replacement instead.
For those who might not be good candidates for conventional surgery due to the associated risks, the transcatheter tricuspid repair is a less invasive option. This involves a doctor guiding a special device through your body’s blood vessels to reach the diseased valve and repair it from inside. The device is usually attached to a long, thin tube called a catheter, which is the reason why this method is called “transcatheter”.
Percutaneous transcatheter tricuspid repair techniques can be broadly divided into three categories: direct suture annuloplasty, direct ring annuloplasty, and coaptation enhancement (which aims to improve the meeting and closure of the tricuspid leaflets).
These procedures are still being tested and improved, but they promise an alternative method for patients who may be unable to tolerate traditional surgical repair.
Possible Complications of Tricuspid Valve Repair
Tricuspid valve repair, which is a procedure done on a heart valve, can sometimes lead to complications. This is common with all heart valve procedures. Some potential issues that can occur after this type of repair include:
- Bleeding during or after the surgery and issues related to blood transfusion.
- Problems with heart rhythm, or arrhythmias, and blocks in the heart’s electrical system.
- Heart failure, where the heart can’t pump blood as well as it should.
- Stroke, a condition caused by blocked blood flow to the brain.
- Infections at the surgery site or in the replacement valve itself.
- Sepsis, a serious illness caused by the body’s extreme response to an infection.
- Problems with the lungs, like pneumonia or a blockage in the lung’s blood supply.
- Kidney failure, which can be a higher risk when using a certain procedure that involves dye, especially if there’s already kidney disease.
- Reactions to medication.
- Mechanical issues with the replacement valve.
The tricuspid valve, one of the four valves in the heart, has often been overlooked in the past when it comes to treatment. When this valve is replaced with surgery, it is riskier compared to other similar procedures. A severe leak of the tricuspid valve (known as severe tricuspid regurgitation) can lead to poor health outcomes regardless of age, the function of both of the heart’s lower chambers, and the size of the right side of the heart. Most often, tricuspid valve repairs are done along with procedures on the left side of the heart.
The best method for surgical repair is called ring annuloplasty, which uses an incomplete semirigid ring. However, some places might do a modified procedure if the ring-like base of the valve is not too widened. As only a small number of patients are suitable to undergo surgery, there’s growing interest in developing less invasive devices for tricuspid regurgitation. It’s likely to see an increased use of these techniques thanks to improved technology and a better understanding of the long-term effects of tricuspid regurgitation.
What Else Should I Know About Tricuspid Valve Repair?
Fixing the tricuspid valve, a part of your heart, is not a common procedure. In the past, doctors didn’t think that issues with the tricuspid valve were serious enough to impact a patient’s health. However, recent studies have started to challenge this thought. These studies have found that if tricuspid valve issues aren’t treated, especially if the patient has other heart diseases, it can increase the risk of illness and death.
If you have moderate to severe issues with your tricuspid valve, it’s important not to ignore it. Over time, these issues will impact your quality of life and your chances of survival. Nowadays, there are more treatment options available for tricuspid valve-related issues, including surgical fixing of the valve and procedures that can be done from outside the body. If you have significant issues with your tricuspid valve, it’s critical to address them.
