 Our next speaker is Dr. David Ladder, and in the ongoing game between Toronto and Montreal, Dr. Ladder is a home run for Toronto. He graduated from McGill University in 1982 and completed residencies in general surgery and CBT at McGill, a clinical fellowship in thoracic transplantation at Stanford. He was on staff at the Royal Victoria Hospital in Montreal from 1991 to 1996. And in 1996, he was appointed to a position at the University of Toronto's St. Michael's Hospital Division of Cardiac Surgery. He has been a professor in the Department of Surgery since 2015. So during his many years at the University of Toronto, Dr. Ladder has held various positions. I'm just going to pick out a couple of them. Chair of the Royal College Examination Board, Program Director of Cardiac Surgery, Acting Chair of the Department of Surgery. He's currently the director of MD admissions and student finances at the University of Toronto. Dr. Ladder specializes in adult cardiac surgery with a special interest in micro valve surgery. And the title of his presentation is surgical decision making during tricuspid valve surgery. David? Thank you. Thank you, Michael. Who's going to advance my slides for me? Will that be you Fatima? David, you can go ahead and share your screen and that should give you control to advance your slides as well. Perfect, okay. So I'm just going to share my screen, right? And I'll just give this talk here. Okay. Sorry, excuse me for the delay. So thank you very much for having me. It's a pleasure to be talking to this group and it's a wonderful meeting organized by my colleagues across the city. I'm very appreciative to be here. I don't have any conflicts of interest. And these are the objectives for this 20 minute talk. Hopefully it will be on time. And we're going to just review some of the issues of regarding decision making in the operating room about tricuspid valve surgery, the indications, and of course some of the techniques that we use. So let's minimize this. This is just something I think you all are aware of in the AHA guidelines of 2020 talking about the severity of TR. And we've changed the name over the years. We now call them stages and C and D are severe TR. The difference, of course, is the presence of symptoms or not. So C is severe without symptoms and D is. And that's primarily where we do most of our interventions on tricuspid valve. It's when they're severe except sometimes when we're doing left side of heart surgery, we may intervene on a patient with only a stage B severity of TR or what we used to call moderate MR. This is the current guidelines, HA guidelines. And I just put this up here as the start of this talk to point out that really there's only one class, one indication, and that is to address severe TR when we are in the operating room doing something on the left side, usually the mitral valve, but it can occasionally be on the aortic valve or even bypass surgery. But that's a one A indication. The other indication that we do in the operating room is really this one here who have stage B, but they have a dilated annulus. And some of my previous speakers, some of the previous speakers have talked about that and I'll address that a little bit more and about where that came from. So you may only have moderate TR or what we call stage B now, but if you have a dilated annulus, you probably ought to be taking care of that in the operating room when you're doing left sided surgery. But it's a 2A indication. The other ones that are in this list are functional TR. And of course, there's a couple here that are talking about primary TR, such as this one here. And we'll talk a little bit about that later as well. So functional TR or what people used to call secondary TR. My previous speakers have talked about this. There's lots of different causes. The most common cause of course is left sided cardiac disease, valve disease or LV function. You can't have pulmonary hypertension. What about right particular enlargement? That's sort of the primary etiology that does happen. I've operated on some of those patients. There's different reasons why that may occur. And this one here that I've listed, long-standing atrial fibrillation and annular dilatation. I didn't think that that was a real thing, but it definitely is. And there are a cohort of patients who have long-standing atrial fibrillation. And for reasons I don't really understand, just seem to dilate their tricuspid valve annulus and develop TR. Dialysis as well. Organic or primary TR, these are some of the causes there are others. Endocarditis is probably the most common one. Trauma is not rare, pacemaker is not rare. But if we have different, we have I think a different indication for surgery when there's a primary valve disease versus a secondary or functional TR. So I'm just going to talk about some of the studies that I think are relevant for the discussion. This was a study in the JTCVS of the Mayo Clinic where they looked at the incidence of TR in their patient cohort, depending on what was the, they all had surgery on the left side, usually the mitral valve. And they noted that the occurrence of TR occurring post-op mitral valve repair was not that great. If the mitral valve indication was for prolapse or a typical mitral valve, you know, a mitral valve MR case where we were doing leaflet, mitral valve leaflet and annuloplasty. If it was for rheumatic mitral valve surgery, the incidence of progression of the TR post-op seemed to be greater and significantly greater. And then in the final sort of group of patients, they looked at if the intervention in the mitral valve was due to ischemic myocardial disease, the progression of TR post-op was the worst. So these things are something that we have to bear in mind when we are faced with decisions to whether or not to intervene in the tricuspid valve when we're operating on the mitral system, mitral valve. This is a study that came out of a hair field by Dr. Dreyfus. He now works in, he's a cardiac surgeon who works in Monaco. It was a pretty important paper and it was a group of patients, they took about, I think it was about 300 patients and they decided that they couldn't rely on preoperative echo assessment to really give them information about should something be done about the tricuspid valve when we're doing mitral valve repair surgery. So they made a decision to just and every one of their patients, they opened the right atrium and did an actual measurement of the of the tricuspid valve and they took a measuring tape, a little sterile measuring tape, they put it at the commissure between the anterior and septal commissure and they stretched out the, they stretched out the mitral valve, the tricuspid valve sort of was sort of linear and just measured the distance from here to as far as they could stretch it out and they found and if it was greater than seven centimeters, so this was when we talked about seven centimeters, we're not talking about a diameter, they're really talking about a stretched out length, they would then intervene on the tricuspid valve with typically an annular plasty and that was probably the predominant the intervention, maybe some some minor leaflet work or you know exclusion of some in large commissures but they did routinely did that and the group that had 70 millimeters or more they intervene and the ones that were less they left alone. They use they use almost exclusively size 32 or 34, 32 in women and size 34 rings in men and they looked at the outcomes and it was really interesting that there was clear, clear benefit for the group that had something done to the tricuspid valve, they had less TR and less CHF but and this is probably true I think in all surgical series the survival wasn't improved, it was still the same survival but they did have less heart failure, less TR and this is I think one challenge that we may see in this sort of new era of perc-tase intervention that yes we can do these procedures and take away the TR but doesn't make people live longer and that is a big question. So currently and I just did a little survey when I was preparing this talk, different centers there's still quite of who have reported on this quite a variation in and how what percentage of patients who are undergoing mitral valve surgery have their tricuspid valve operated on at the same time. The Mayo Clinic in Toronto General it's like less than 10%, Mount Sinai in New York this is David Adams group it's as high as 65% and other centers Pennsylvania is very high, Herfield takes an aggressive approach and they're sort of intermediate but that's quite a large variation between you know prominent centers that are doing as low as 10% or as high as 65% intervention rates on the tricuspid valve. So when we decide what we're going to do if we do anything on the tricuspid valve it's really important for us to consider the anatomy and that's why I really appreciated Dr. Vegas's talk and Dr. Armrand where they really talked about the anatomy to help the surgeons make decisions and these are of course really important things. The angular dimension we currently use at St. Michael's and I think most people use preop echo measuring 40 millimeters in the dimension between the middle of the septal leaflet to the middle of the anterior leaflet in biastically preferably in the four chamber view. Perhaps it's more accurate if you used an indexed version of that so some people are bigger or smaller but this is a pretty useful number 40. The RV size is important I don't know any really good measurements of that or even also important is the RV function hard to measure that and get something that we can make decisions based on that with leaflet tethering, commissure and scallop depth. So I'm going to show you a picture where the tricuspid valve is very variable with its anatomy and some of them have really deep scallops in the anterior leaflet that looks like it's a fourth leaflet. The severity of TR of course if it's three plus or more then I think we ought to do something if it's two plus then we can make some decisions and of course the severity of TR fluctuates. It fluctuates preop. If you happen to do the echo on the patient a day when they're well dire yeast you may have much less TR than a week later when they've consumed too much fluid, they've stopped taking their Lasix or whatever is going on and we certainly see that in the operating room where intraoperative assessments of TR are always less than the preoperative assessments. So one of the issues about leaving the tricuspid valve of course and this is what we're really talking about here what is the consequences of that. I don't think there's much different there's certainly no change in mortality in the short term and I think I would I'm hard pressed to find any papers that show a long term difference of whether the tricuspid valve is intervened on at the time of mitral valve surgery that affects survival but we do know the TR gets worse over time and severe TR definitely gets worse and we do know that dilated tricuspid valve analysis lead to TR and that gets worse over time and these factors female atrial fib diabetes they seem to promote progression of TR and again I talked about the mixed rates of intervention and of course the real problem is this last comment here is that if you don't do something at the time of the first surgery and then five years later the patient has had severe TR and is really struggling the operative mortality risk is probably at least 10% on those patients and so that is a significant risk to the patient to start to consider surgical intervention at that time. Um that a paper from Mount Sinai that said that indicated that 65% of their patients that they were operating on the mitral valve or having something done to the tricuspid valve was actually presented at the AATS meeting in 2015 and actually was quite controversial led to a lot of sort of discussion at the time and Tadrone Beva got up and said that that's crazy or over-treating. Anyways this fellow Robert Dion who's a well-known cardiac surgeon who works in Belgium now wrote an editorial on the JTCVS and he basically summarized I think the current thinking and gave some recommendations which I listed here so if the TR is greater than or equal to plus you should do an annual plastic at time of mitral valve surgery. If it's greater than two plus and tenting you should do an annual plastic and leaflet augmentation which I'll show you in a minute sort of pictures of that. What if the TR is less than two so you're talking about you know he's talking about modern TR or mild and but they have an annulus that's greater than 40 millimeters he recommends doing an annual plastic and he even goes so far that if it's if your TR is you know like one plus and but your annulus between 3.35 and 40 maybe if you have these other risk factors you should consider surgery as well. This is what I do now I think it's a reasonable approach similar to what the previous slide just showed. Severe TR you have to intervene. Modern TR for annular dilatation you have to intervene. We know TR progresses the incidence of significant TR after MBR if it's left untreated is at least 25 percent in the five to ten year range. The mortality of a isolated tricuspid valve replacement or repair surgery is high especially for redo surgery and there is even though there may not be a survival benefit there is a significant impact on the patient's quality of life in terms of heart failure. So this is the current 2020 guidelines from AHA and I just want to put this up here to point out that the only class one indication is this one which is at the time of left side of surgery if you have severe TR you have to do something. The other one that I think is pretty straightforward again at the time of left side of heart surgery is this other column here which is only stage B or modern TR but with annular dilatation that's a 2A indication so these two I don't think there's too much controversy about. The ones and then these two the one the second from the left and the second from the right these are primary tricuspid valve problems so they have a ruptured cord or endocarditis and they have a hole in the leaflet and I think we really ought to be repairing those especially if you're having a right heart failure and you have primary TR you should have surgery. This one what about this one these are asymptomatic patients they have severe TR but asymptomatic and I think you probably shouldn't intervene on these patients before this progresses to severe in severity or especially with symptoms but it's only a 2B recommendation and then this was the one that's probably the biggest category of them all which are patients that have functional TR secondary TR and they have right heart failure they're sick and what do we do with them so if you don't have pulmonary hypertension then yes surgery seems indicated annular dilatation is easy to fix with an annular plasty other things like tethering or RV dysfunction are much harder to fix in fact cannot be fixed RV dysfunction with surgery and the reason why this third column over here is a 2B is because this is their reops they've had previous surgery and the risk of surgery is higher so the indication seems to be a little less strong. Let's pass over that again this is for organic TR which we do operate on especially if they're having if they're severe and they're having and they're symptomatic these are the different techniques we can use and I'm going to show you some diagrams or pictures of these but basically the answer is you know you fix you fix what's broken so this is the anatomy the tricuspid valve this is a typical surgeon's view I wish it actually looked like this when we opened the right atrium in the operating room it's all nicely labeled this is the coronary osteum so this is a useful landmark for us because we know somewhere around the middle of the septal leaflet to the to the commissure is the conduction system which we want to avoid so we don't ever want to really be putting stitches in here this is a triangle of of cauch, caution there's a tendon here called the tendon of Tadaro which we can easily see and that triangle we don't really want to be putting stitches in so that's why annual plastic stitches we'll start about here and go around this looks very nice three leaflets easily identified no deep clefts it really rarely looks this this neat but that is the sort of the anatomy of the tricuspid valve this is what annulus annual plastic looks like this is some people recommend putting a pledging stitch here this is sort of in the orifice of the coronary sinus does a lot to coronary sinus but that's where it's tethered where or based out of and we're avoiding this area because that's where the conduction system is and that gives a nice closure this is one that looks in the operating room this is an older style tricuspid ring carpaccia which ring the newer ones are a little bit shorter here again you sort of you can see one two three four leaflets you say well what's what well you know sometimes it looks like that it's not doesn't look like this very often it's it can be quite variable in this appearance by cuspidization so if you have a prolapsing posture leaflet this is septum this is posture this is anterior this used to be a technique that was done quite frequently we just take it out of the circuit you know plica it out and some surgeons in the you know early days just left it but most people would put a ring on here now to reinforce that someone talked to Dr. Vegas talked about leaflet tethering this is a very real phenomena when the RV dilates and everything moves away from the tricuspid annulus so we would have to put a ring on there to reduce the size annulus but the deal with the tethering it's been suggested that pericardial patches put in so I take a piece of the of the patient pericardium and just stitch it into elongate the anterior leaflet and and make it and close the commerce close the class to make it the competent this is like something called the clover technique so again it would be with an annual class this is really useful for people with prolapsing leaflets so that's more of a primary cause of tr and you just it's like an alfieri stitch of course it looks similar to the what would be done with clips but with a stitch pacemaker reduced we do these kind of repairs we would move them out of the anterior leaflet if it was stuck there we close it and put it over to the side in the commissure area and this is this is hard to do these are putting artificial cords because the right ventricle is so large it's so dependent on size it's really hard to get these the right length so they're they're kind of hard to do and they can be done if you have to but it's difficult to get them right and this is going to show you a couple pictures at the end of my talk this was the case that we did about a year ago we have a very active a group of cardiologists that put all sorts of devices in and this is an evoke valve that went in that unfortunately had to come out because it embolized it looks enormous looks like a UFO it looks enormous because it is enormous it's like 45 millimeters in diameter and then this is a case my last couple slides is that as a young fellow who is a stuntman who fell falling out of a window I think on a movie set landed on his chest suffered a pretty significant right ventricular myocardial contusion was in hospital for a week or two you know initially had some arrhythmia as they settled down had no rupture to his check up a valve but over the year he developed severe TR and I was I ended up operating this fellow and his because of his contusion from his right ventricle his right ventricle got got larger and everything was pulled apart and dilated and this is his anterior leaflet actually with a deep clef that normally is not a problem with a normal sized right heart but in this patient was being held open and he had severe TR through that area and here's his posterior leaflet and his septior leaflet and you can see almost there's like a gap between the septor except the septal leaflet and the posture leaflet work just can't close so I addressed those things I sewed this up the the cleft the anterior leaflet I placate this out with a sort of bi-cospitization technique and put a ring on there and unfortunately the picture didn't come out very well but it worked very well and that was a successful sort of treatment of what I think is primary TR but really is probably from his right ventricle so thank you for that well and thank you David that is fantastic it's always great to see stuff from the operating room to see what's what's going on so we'll we'll move along