Valve tricuspide : indications et solutions percutanées Pascal Lim

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Pascal Lim
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CHU Henri Mondor, Créteil
[email protected]
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Valve tricuspide : indications et
solutions percutanées
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The number of moderate to severe TR is estimated at 1,6 millions in US
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Moderate to severe= 0.8% of Framingham population and 10%
of adult population referred for TTE
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Prévalences of TR
Jagmeet P. Singh, Am J Cardiol 1999
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20-30% of left side desease are associated with
moderate to severe TR
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Functional TR (80%)
Predominant etiology
De Meester et al. Acta Cardiol 2012
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Prévalence des IT après chirurgie du cœur
gauche
• Prevalence of TR after valvular surgery (n=539 patients –
17% of moderate to severe TR 50±15 after surgery)
Kammerlander, A, JACC
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Prévalence of TR in TAVI population
N=518 pour TAVI
IT grade III-IV de 15,2%
Persistant dans 68% des cas post TAVI
Marco Barbanti, Catheterization and Cardiovascular Interventions 2015
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Severe TR is an independant predictor of survival
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IT fonctionnelles et Pronostic
Jayant Nath, J Am Coll Cardiol 2004
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ESC Guidelines 2012
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Despite a decrease in surgery risk, less than 1% of patients are
refered to cardiac surgery because of advanced RV dysfunction or
high operative risk
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Surgery
Rogers Curr Opin Cardiol 2014
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Femoral access – 24F
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High sucessful results – Indicated in patients with tricuspid bioprothesis regurgitation
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16 patients (31 years, 14 congenital diseases) with tricuspid bioprothesis valve dysfunction
(14 moderate to severe TR) - Melody (n=7) and Sapien (n=10)
All sucessfully implanted, one early severe TR (Melody), one late stent fracture (Melody)
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Hager et al. Circ Cardiovasc Interv, 2015
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Valve in Ring
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Suboptimal results but may be usuffull in severely symptomatic patients
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3 patients with Carpentier-Edwards ring (Ø=30mm (n=2) and 32mm) and severe TR
Sucessful implantation of a 26mm SAPIEN XT valve
Two with residual TR (one severe) but all clinically improved
Bouletti et al. Circ Cardiovasc Interv 2015
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The TriCinch System
PREVENT study. NCT02098200
Severe functional TR after MVR (72-years, STS=5.2%, NYHA III) with right ventricular
Clinically improved and TR grade IV to grade III
Azeem Latib, JACC cardiovascular intervention, 2015
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Symptomatic severe TR (89 y, Eurscore 28%) with severe kidney injury (MDRD=27ml/min)
and RV dysfunction
=> Reduce TR and increase SV – Clinically improved and renal function
(MDRD=55mL/min)
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The Mitralign System
Joachim Schofer, JACC 2015
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One third of TR repair failed at 5 years (Grade ≥3/4) – Especially in presence
of tenting (>8mm or 16mm²) and RV dilatation
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Limitation of Repair
Guillaume Marquis-Gravel, Am Heart J 2012 - Shota Fukuda, Circulation 2005
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First in man with Lauten device
3 patients implanted with EDWARDS valve (Sapien XT 29mm+2 stents)
Clinical improvement of sign of RV HF – Palliatif treatment
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Caval Valve Implantation
NCT02387697 (EDWARS)
Lauten et al. EHJ 2011 - Laude et al, JACC 2013
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The FORMA system (Edwards)
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NCT02471807 - (Edwards – FORMA)
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Population: Symptomatic severe TR (Grade IV, n=7, 76 ± 13 years) with
high risk surgery (EuroSCORE 25.7 ± 17.4%),
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Feasiblity: succesffull in all and no complication
Improvement: All clinically improved but 1
Reduced TR with moderate TR in 3 and mild TR in 4 patients
Campelo-Parada, F et al. JACC 2015
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No specific landmark and tissue at annulus level
RV and RA thickness
Conduction fibers and coronary sinus and RCA
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Complexity of Tricuspid Anatomy
Normal=28±5mm²
Surface =8cm²
Variation de surface 30%
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Tricuspid Valve Replacement
The future
Under investigation
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Broad Ranges of Tricuspid size
Personal data
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 Valve in valve with Edwards or Melody valve is
feasible and provides good clinical results
 Valve in ring can be proposed in severely
symptomatic patients when no alternative exists
 Devices aim to reduce TR severity or organ
congestion are under clinical validation
 Full tricuspid valve replacement are at the
prototyping stages because of the complexity of
tricuspid anatomy
20
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Take Home Message