Ask the Heart Doctor: Tricuspid Valve Surgery

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic’s Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Amar Krishnaswamy, MD:

Thank you, everyone, for joining us. This is the edition of Ask the Heart Doctor, where we're going to focus on valvular heart disease from diagnosis to treatment. My name is Amar Krishnaswamy. I'm the section head of interventional cardiology, and I specialize in the transcatheter treatment of valvular heart disease.

I'm joined today by a fantastic panel of colleagues and friends. We have Dr. Xiaoying Lou, who is a cardiac surgeon and an expert in aortic valve surgery. We have Dr. Tarek Malas, who is also a cardiac surgeon and an expert in mitral valve surgery, and Dr. Serge Harb, who is one of our cardiac imagers and a specialist in the diagnosis and guidance of transcatheter heart procedures with cardiac imaging.

We appreciate your engagement in this program. We've received almost 250 different questions. We're going to try to do our best to answer as many of them as we can in a comprehensive fashion. But please, if there are questions we don't answer, feel free to reach out. There will be contact information at the end of this program.

 I'm going to turn our attention now toward tricuspid valve pathology and tricuspid valve regurgitation. For a long time, this was a valve that perhaps people would have treated if they were having another cardiac surgery, and then you guys would go ahead and repair the tricuspid valve itself. But in more recent times, we've become more attuned to people who have symptoms as a result of isolated tricuspid valve regurgitation or perhaps the long-term ramifications of tricuspid valve regurgitation on the heart and the quality of life.

So perhaps Serge, I can turn it back to you. In patients with tricuspid valve regurgitation without other valvular heart disease, perhaps they've had valve surgery in the past that's functioning well. How do you analyze the tricuspid valve? Again, getting back to one of our early questions, if someone has a mild or a moderate degree of tricuspid valve regurgitation, do those patients need to be followed? And then finally, how do you make a decision to say, should that patient be referred for a transcatheter or a surgical treatment of their tricuspid valve?

Serge Harb, MD:

As you mentioned, the tricuspid valve used to be the forgotten valve, and now there is so much attention on the tricuspid valve. In terms of evaluation, the most important test to start with is an echocardiogram just to understand the amount of leakage and the consequence of such leakage. Meaning is it causing right-sided enlargement and is it a result of high pressures within the heart? Once we've made a determination about the severity of the leak, then the follow-up and the management depends basically, on how bad it is. Typically for mild conditions, we tend to follow them up probably every three to five years, depending, most importantly, on patient symptoms. For moderate lesions, it's more frequent, maybe every one to two years. Then for severe lesions, then we are really considering if there is a need for intervention.

The decision to intervene, as discussed before, is mainly based on three criteria. One: patient's symptoms. What are the symptoms of tricuspid leak – mainly fatigue, leg swelling, abdominal distension, hepatic congestion, and being short of breath. If there are no symptoms, then what we're looking at is, are there any signs of heart damage? Meaning heart damage in the tricuspid side, is there a significant right ventricular enlargement? Is there significant right-sided dysfunction? Lastly, in some cases, when there is a severe leak, we may consider intervention if the patient is asymptomatic. But these are very much case by case and a multidisciplinary team approach, as Dr. Malas and Dr. Lou have been mentioning, where we sit all together, minimally invasive interventionists such as Dr. Krishnaswamy, or surgeons, and then we make the decision to intervene. Once we've made the decision to intervene, then the question is, is surgery the best route or is a transcatheter minimally invasive option the best route? Again, it's a team approach.

We have every patient, once they're done with their testing, meet a surgeon and meet a team member in the structural team, and then we have a discussion. We weigh the pros and cons, taking into consideration the patient's preferences, the patient's expectations, and then make a decision about what therapy is best. Especially now that the FDA has recently approved two transcatheter options, one for repair, which is edge-to-edge repair as Dr. Krishnaswamy has mentioned, and then replacement. The decision of repair, replacement, minimally invasive [surgery] or surgery is a multidisciplinary team approach.

Amar Krishnaswamy, MD:

Thank you, Serge. Before we get into the details of either a transcatheter treatment strategy or a surgical treatment strategy for a tricuspid valve regurgitation, can you just touch on some of the associated conditions with tricuspid regurgitation and how do we involve our electrophysiology colleagues with regard to heart rhythm management strategies? Also, how do we involve our heart failure colleagues with regard to the medical therapies that are there?

Serge Harb, MD:

Most tricuspid leaks are a result of associated cardiac conditions, meaning a small percentage are related to just the valve having a problem in itself. As opposed to the mitral valve, where we spoke about prolapse or flail, it's quite uncommon on the tricuspid valve. Most tricuspid leaks are related to associated cardiac conditions such as heart failure, pulmonary hypertension, and other valve disease on the left side. Then very importantly, what Dr. Krishnaswamy mentioned, is the involvement of the electrophysiologist. The reason why is it's not uncommon for a pacemaker lead that's crossing the tricuspid valve or a defibrillator lead that's crossing the tricuspid valve, to be somewhat a culprit in the initiation or even in the progression of tricuspid leaks.

Once you start dealing with a lead that's interfering or causing the leak or even interfering with the therapy that can be offered, meaning if the lead is in a place which makes it challenging to repair it via a minimally invasive route, then we involve our electrophysiologists to try and discuss plans about how to manage the lead. Should we remove it? Should we replace it with a leadless pacemaker, meaning a pacemaker that doesn't cross the tricuspid valve, that just sits in the right-sided chambers? Or even a surgical option of leads outside, not through the tricuspid valve? Or maybe a defibrillator underneath the skin?

Also, we involve our heart failure colleagues for multiple reasons, mainly to help us manage a right-sided failure with mainly diuretics and other treatment. But also because sometimes tricuspid leak is a manifestation of a global heart disease and then a heart failure where the left side is weak, and it's causing the backfilling and increased pressure in the heart, leading to tricuspid leak.

It's truly a multidisciplinary approach. It's a very complex valve condition to have. We have treatment options, it just involves multiple people from multiple specialties, all sitting at the same table and trying to figure out what would be the best option for this specific patient.

Amar Krishnaswamy, MD:

That's really helpful. Great insights, Serge, into the patient journey and the number of different people that they'll see if they're coming for treatment for tricuspid valve regurgitation, to make sure that we're hitting all of the points of how they need to be treated. A number of questions here about surgery and transcatheter treatments for the tricuspid valve. I'll start on the transcatheter side. As Serge mentioned, earlier this year, we had a couple of transcatheter treatments for the tricuspid valve that were approved by the FDA. One is the EVOQUE transcatheter tricuspid valve replacement, and the other is the TriClip, which is a TEER [transcatheter edge-to-edge repair] device, just on the mitral side instead of on the tricuspid side. There are a number of questions here about how these procedures are done, how the results compare. I'm just going to try to address this from a 30,000-foot view.

Both of these procedures, transcatheter tricuspid valve replacement or transcatheter tricuspid valve clipping or TEER are done under general anesthesia with a breathing tube in. We place the device at the femoral vein at the top of the right thigh or the left thigh. Through that tube, we take the device up to the tricuspid valve. For the valve replacement, we push aside the native tricuspid valve, leaving the EVOQUE valve in place. For the tricuspid valve clipping or TEER, we simply bring together the edges of the tricuspid valve, similar to what we would do on the mitral side for TEER.

There have been no comparisons of the transcatheter tricuspid valve replacement with the TEER strategy or repair strategy. Really, these decisions are made based on patient-specific anatomies. For those patients who have a suitable anatomy for clipping, that's often the way in which we will proceed. For those patients who are unsuitable for clipping, we usually use the replacement strategy. Patients often ask if they have a lead in place, as Dr. Harb mentioned, sometimes the lead can interfere with the tricuspid valve function and cause leakage. We often can still do clipping for those patients.

If clipping is not suitable based on that anatomy, and there's a lead through the tricuspid valve and we plan to do a tricuspid valve replacement, we'll often have our electrophysiology colleagues involved to decide if they need to remove that lead, not because it's going to make the regurgitation better, but because we don't want to trap that lead behind the prosthetic valve that we're going to place. The reason for that concern is that all leads have a certain risk of infection on an annual basis. If the lead gets infected and it's trapped behind a transcatheter valve, it can be very complicated or nearly impossible to then extract that infected lead. So again, it's a very important thing to have a conversation between the implanting team and the electrophysiology team to really decide for a given patient what's the right strategy for that lead management.

These transcatheter treatment strategies have become much more popular in recent years, and with a lot more study, primarily because surgery was historically considered a very high risk for this group of patients with isolated tricuspid valve regurgitation with concerns about both the surgical treatment and the recovery from surgery. That's really where the transcatheter treatments came about. But what we have found, as we've seen more and more patients with tricuspid valve disease, and oftentimes who have not been good candidates for a transcatheter treatment strategy, that our surgeons have taken them for what were, again, historically considered high risk surgeries, but really with very effective treatment and good outcomes.

I'll turn it over to Dr. Lou and Dr. Malas. How do you guys approach tricuspid valve disease surgically in the current time?

Xiaoying Lou, MD:

What we're all getting at is, actually, the tricuspid valve, an isolated tricuspid valve lesion where only that valve is affected and none of the other valves are affected, is not that common. It's not as common as the other valves being affected. For isolated tricuspid valve disease, very much as everyone has mentioned, it's a heart team approach to figure out what the best thing to do for that patient is, and also to assess how leaky that valve truly is. If it is, in fact, that we're going after this for tricuspid insufficiency because it is a valve that's very dependent on the patient's status overall, their heart function status and their volume status. We see it in a lot in patients who have overall a lot of volume on board, and then that valve is quite leaky when their fluid volume is up inside their bodies and when they've diuresed it, or sometimes in kidney patients when they haven't had a dialysis session in a few days. They get that off and that valve magically looks a little bit better on the echo study. It's no longer severely leaky, it's only mildly leaky.

It is sometimes very dependent on all of those things. I think we do all of these tests and sometimes we need to do invasive testing, as Dr. Harb was saying, with right heart catheterizations to look at whether there's truly an indication to go after this valve. Because, from a surgical perspective, there are things we can do to repair this valve. Typically, when we see it in the setting of, if we're going after left-sided disease because everything from the left side is leaking backwards to the right side, and the right side has been problematic or it's an ischemic issue, putting just a ring around that tricuspid valve and tightening the waist of that valve a little bit will solve the problem and that valve becomes no longer leaky afterwards.

It is a valve that I think is “less is more.” It helps for that particular valve. Patients can tolerate some degree of leakiness. It doesn't have to be, as you were saying, an A+ situation on that valve. Even some mild leakiness on that valve, patients generally tolerate that very well for their whole lives.

The other option, we don't like to do this, and I think it's very rare that we end up doing this, is to replace that valve. The reason being that it's on the right side of the heart. There is just slower-flowing blood flow across that side of the heart, so there's a greater risk of things clotting around that valve, even when it's a tissue valve and the conduction territory is right there.

Anytime we put in any valve where we have to put stitches around where that valve sits is where all the conduction inside the heart is going on. It really can affect the conduction system. Then we're looking at not just the valve getting put in, but also putting in a pacemaker for that patient. It's definitely a tricky valve. We are, as a surgical society, are also trying to figure out better ways to treat this valve, better repair techniques. It’s not very often that we're actually replacing this particular valve.

Tarek Malas, MD:

Sometimes you can replace certain parts of the valve with what we call autologous tissue, tissue from our own body. Sometimes we can place cords to try to repair that valve. But in the majority of cases, sometimes just protecting the waist with a band is sufficient to get the outcome, especially if the valve is dilated with time. Bringing that together can solve and bring the leaflets back together. Just to echo Dr. Lou's comments as well, generally speaking, it's pretty rare that we do an isolated tricuspid valve replacement. Having transcatheter options has been fantastic. We rely on our colleagues like Dr. Krishnaswamy to provide guidance as well on that.

Amar Krishnaswamy, MD:

Thank you guys. Just as we close out, a couple of final questions here. Serge, someone has had their valve repaired or their valve replaced, whether it's by a transcatheter means or a surgical means. How often should that patient be seeing their caregiver, both for clinical assessment and for an imaging evaluation of that result?

Serge Harb, MD:

It really depends on the success of the repair or replacement, and also patient symptoms. Generally speaking, we tend to at least follow them yearly. If there are problems, if they have symptoms, if the valve repair was not that successful, the valve replacement is starting to show some valve dysfunction, then, of course, it's going to be more frequent. It's typically guided by the patient's symptoms, the initial repair and the findings on the follow-up echocardiograms. As you said, it's mainly a follow-up with physical exam, symptom assessment and also echocardiography.

Amar Krishnaswamy, MD:

People often ask how long they need to take antibiotics after a valve repair or a valve replacement, if they're having dental work or some other surgical procedure. What's the general recommendation?

Serge Harb, MD:

The general recommendation, if you had prior surgical intervention with surgical material or transcatheter material inside the heart, we recommend an antibiotic prophylaxis before invasive dental procedures. For general dental cleaning, the risk is quite low, but for more invasive stuff, such as tooth extraction, an abscess, manipulation of the gingival tissue, or perforation of the oral mucosa, anything that's invasive we recommend antibiotic prophylaxis. Typically, amoxicillin, two grams just half an hour to an hour prior to the procedure. This is a typical recommendation to prevent endocarditis, which is an infection of the surgical material or the transcatheter material that's inside the heart. We also are very vigilant in patients who have prior infective endocarditis to recommend the prophylaxis and in patients who have some conditions of congenital heart disease.

Amar Krishnaswamy, MD:

Very helpful. Well, thanks again to Dr. Harb from Cardiac Imaging, Dr. Malas from Cardiac Surgery, Dr. Lou from Cardiac Surgery. To those of you watching, we appreciate your time. Take care.

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