 Hello everyone, my name is Max Meneri, I used to work at Toronto General Hospital and now I'm at Leipzig-Herzentrum, I'd like to thank the organizer for giving me the opportunity to present the 19th Annual Toronto Perioperative TE Symposium and before I start I'd like to congratulate everyone involved in the organization for doing a phenomenal job in a very difficult time. I'll be talking about tricuspid regurgitation and unfortunately I couldn't connect live because I'm actually Covid positive, fortunately with minimal symptoms both my kids at home so it was going to be difficult to keep them quiet during the whole time I was going to be presenting. I don't have any competing interests with the only exception that I'm work at Leipzig-Herzentrum that's a reference centre for Philips and I'm part of the writing committee for the basic TE exam at the National Board of Echocardiography. I'll be presenting two cases, the first case is a 74 years old female that presented for a elective surgery in our operating room with chronic chronic atrial fibrillation, diabetes, left ventricle ejection fraction 60% and a pulmonary arterial pressure of 48 plus CVP. The preoperative echo showed severe matter regurgitation and it was the main reason the patient came to the operating room and moderate tricuspid regurgitation. Now the surgeon in this case as in most of the cases at our centre wanted to do a minimally invasive approach and we would normally don't place a superior vena keva canula or a jugular bypass canula unless we do a tricuspid valve repair so for microvalval alone we would not place a canula we would if we do the tricuspid valve alone. So the patient comes in the and as soon as the patient is intubated my junior would start doing the echo and as he does the echo then he asks the nurse to come and to give me a call and so I come in and I look at the echoes and as you can see in this four chamber view the both atria seems to be predilated there is definitely dilated left ventricle but as we look at the tricuspid valve annulus it doesn't look so big or at least not as big as I would expect it and there's not much of a tricuspid regurgitation and I start looking around and looking around I hold the probe now and in this modified four chamber sort of something between four chamber and RV inflow outflow view I could get a regurgitan jet that wasn't even big enough to actually measure a vina contracta and now my junior had already measured the tricuspid annulus and in this first measurement the annulus is 3.2 actually looking at this picture this is not like sort of an ideal sort of cut to measure the annulus and that's why I decided to remeasure it again and as I remeasure it again then maybe trying to be generous I could find an annulus of 44 millimeters so here we have very little tricuspid regurgitation and we also have a dilated annulus more than four but not that dilated so now the question is yeah what shall we do so I'm gonna give the surgeon a call and I'm gonna let him know and then we said I'm on my way and in the mean we used 3d technology to get some extra pictures and here is the four chamber so from the modified four chamber view I got a 3d block and then with color now we can actually see in the center of the valve on the right that there is a little bit more tricuspid regurgitation with sort of tracing and multi-planar reconstruction we actually found a vina contracta area of 0.66 and a vina contracta width of 0.6 here on 3d when we look at the guidelines actually this qualifies for vina contracta width which is not necessarily validated to be measured on 3d but sort of for moderate tricuspid regurgitation and actually for vina contracta area with 3d we can only define severe and nothing that's less than severe so if more than 10 centimeter square is severe if it's less than 10 then it's not severe so in this case it's definitely less than 10 is not severe and we sort of now sort of probably agree that there is a there is tricuspid regurgitation probably moderate and there is a slightly so now in terms of surgical decision making here is where it becomes tricky because like we have preoperative data we have interoperative data preoperative data are based on trans thoracic interoperative data are based on trans esophageal echo and these are just a few information within a much bigger sort of picture which is sort of a patient with comorbidities with sort of a whole clinical history atrial fibrillation the latest atria so what would sort of the literature yeah so we know that and this is so now i'm working germany so i'm glad to present german data but it's sort of from the from the sort of the equivalent of the sts database from germany we know that tricuspid valve surgery alone yeah regardless is definitely 10 times higher risk of mortality than any other surgery so definitely operating the tricuspid valve alone eventually in the future it's probably not a good option what we actually know is from this key sort of paper from dracus from 2005 is that if you repair the tricuspid valve at the time of mitral valve repair the mortality doesn't change and what does change is that the patients who had mitral and tricuspid valve at the same time they won't develop tricuspid valve regurgitation in the future when those where we didn't repair the tricuspid valve they would then develop tricuspid valve regurgitation in the future probably the reason for the guidelines from AHA ACC from 2014 suggests that in case of tricuspid regurgitation if you have a severe tricuspid regurgitation and you do left heart surgery you definitely need to do something to the tricuspid valve when it becomes a little bit tricky is you have mild or moderate tricuspid regurgitation and then you need to decide whether the annulus is dilated or not and the cut off for dilated annulus is four centimeters measure in a four chamber view and in this case our case for 4.2 and if there is only tricuspid if there is tricuspid valve annular dilatation it's a class one indication place 2a indication and if there is a not tricuspid valve dilatation but there is pulmonary hypertension then it's a class 2b indication in our case we actually probably can classify although sort of on borderline this patient for class 2a so with left heart surgery moderate tricuspid regurgitation the european guidelines are not very different and again with severe tricuspid regurgitation left heart surgery there's a category one mild moderate tricuspid regurgitation if the annulus is dilated or there is a pulmonary arterial pressure systolic more than 60 then it's a class 2a indication so that's definitely the case for so the surgeon said you know what max i'm sorry i got your point but really in this patient knowing her history and looking at the dilated atria although i know it's not part of the decision making process but still i decided i think you should just put a superior vena keva canula through the internal jugular vein and then i'll do a mitral valve uh i'll do the tricuspid valve together with the mitral and this was sort of for chamber view with x plane offer repair mitral valve that was successful through a smart or economy and at the same time you can see here we also place a nice ring on the tricuspid valve and there's no regurgitation so the sort of key point and take on message from this first case is that as we know tricuspid valve alone uh surgery carries a high mortality and and sometimes we play a significant role in making the decision and i think i based on that and based on the fact that the surgeons are having more and more um confidence in repairing tricuspid valve then there is a tendency um to um have a lower threshold to repair the tricuspid valve nowadays than there there was probably a few years ago and especially because there is no significant increase in um in mortality now the other problem is that we typically assess the patients pre-operatively in in in determined physiological circumstances and now the patient is assessed again intraoperatively in a completely different physiological circumstances so it's difficult to compare the two type or the two time points and is and it's uh as as for other valvular lesions ideally this type of discussions or this type of decision should be made based on the pre-operative echo instead of uh waiting for the intraoperative echo a different story is when the patient comes and there's no known tricuspid regurgitation and now suddenly we find tricuspid regurgitation that is probably where our uh intraoperative finding can definitely make a difference and when we do do an intraoperative assessment using all the tools uh that are available to us actually in our case with 2d images alone we could barely see any regurgit and jet and then when we actually use 3d we could actually see a jet it was sort of after a few minutes and I mean the physiological hemodynamics may have changed but uh still use all the tools you have in order to better define your tricuspid jet uh now as a technical uh discussion uh this is functional tricuspid regurgitation it's due to the distortion of the relationship of not just the annulus or the leaflet but the whole tricuspival complex which includes the atrium the annulus the leaflet the cordae the popular muscle and the right ventricle so changing any of these components then can lead to um tricuspid regurgitation now in case of functional tricuspid regurgitation the mechanism is the annulus dilation and because the septal leaflet is attached to the interectrial septum more than the other leaflet to this to the lateral wall then there is a tendency for the septal leaflet to not to adjust to an annular dilatation and leave a gap in the center with a uh um regurgitan jet that typically it's directed against the interectrial septum so as a technical um sort of uh sketch here to display the different options for tricuspid valve repair there is the typical um there's a few techniques so one is to put a bend and put a ring and just make the annulus smaller another option is the so called the vega technique where instead of putting a ring we just run a suture along the annulus and then we um we pull it and and that would sort of do it and then the third option is this so-called big cuspidization of the valve where basically one uh commissure is basically uh uh suture together so then we basically have like a three cuspid tricuspid valve we can make it a bi- valve what's a bit tricky about the tricuspid valve is that um there is a funny triangle that's called the triangle of Koch and it is defined by the so-called tendon of Todaro that goes from the top of the coronary sinus to the um uh commissure between septal and anterior uh leaflet of the tricuspid valve and that with the um uh edge of the septal end of the annulus of the tricuspid valve constituted triangle and at the apex of this triangle comes the AV node so and that's the reason for the annular eye that are typically used this is a so-called physio ring um they are not a full ring but they are open ring and this open ring is left open in order to sort of try to stay away from the um AV node that's uh sits just right there at the apex of this triangle here we go with ship ears and i'm in good time 15 minutes so far this is a slightly sicker patient so 86 years old female chronicator of fibrillation she has a permanent pacemaker for complete block uh diabetes COPD normal left ventricular ejection fraction elevated pulmonary artery pressure memory current asides and admissions with right heart failure the patient was by multiple echo pre-op and uh this is the trans thoracic echo that shows that mild tricuspid regurgitation sorry mild mitragurgitation and severe tricuspid regurgitation and that's um given her picture and the isolated tricuspid problem then they decided to use a percutaneous technique we have two types of percutaneous techniques that we use at our center for a tricuspid valve uh one is the triclip and the other one is the Pascal system both work in a very similar way these are clips that basically grasp the leaflet both now can grasp the leaflet uh independently so one independent from the other uh the the clip is the leaflet are grasped then the clip is closed then we assess for the results if you're happy then we can decide to release the clip if we're not happy then we can reopen and then we can we can re-grasp yeah so very similar to what we do for the mitral valve with the difference that here we are going to we're not going to re-accept this is the baseline assessment of this patient uh as expected for chamber view in the left on the left side we have a very dilated right side of the heart uh there's a dilated tricuspid annulus and on the right side we can see that there's a bright broad base uh tricuspid annulus here is inflow outflow view with x-plane and we can see this broad base jet and we can on the right side uh from the color x-plane we can see the pacemaker wire there and we can see that the the gurgian jet comes right next to the pacemaker wire to the right is the transcastric short axis view of the tricuspid valve where we can see that there is a large jet that comes from the anterior and septal leaflet and then extends a bit more posterior also with the origin of the jet between the posterior and the septal leaflet and we can clearly appreciate there the um pacemaker wire that's against the inter uh against the septal leaflet of the valve this is in four in in 3d to the left we have a 3d and to the right is 3d with use the 3d with color again to better quantify the tricuspid regurgitation and here it there's no doubt this is a severe tricuspid regurgitation with a vina contracta cross-sectional area of one square so then this is the view this transcastric view is what we typically use for planning our uh procedure and here what we plan was to start with one clip between anterior and septal leaflet uh towards the anterior commissure and a second clip more towards the center of the and here we have fluoroscopy that sort of guide us and we're lucky at the health center leipzig we have a screen that shows the fluoroscopy that's just above our tea machine and here you see that there's the introducer that comes to the right uh atrium so we need to follow the clip the clip comes out of the introducer here the clip is actually uh getting close to the interatrial septum we need to tell the cardiologist i mean they usually look at the screen as as they do this but although we know that also there's uh uh typically this patient come with a very dilated right atrium so there's quite a lot of room for movement for the clip and the delivery catheter but still we need to be very careful because there's a lot of critical structure that can be eventually perforated here the clips come closer now to the superior vina cava and rotate close to the aortic valve and now the clip is now diving going down into the tracastrid valve and this is uh the clip above the tracastrid valve and now with the x-plane we can tell the cardiologist the correct orientation of the clip to the left we can see in the inflow outflow view we see the clip in its long axis which is non-correct and it rotated the clip 90 degrees and now it's in the right orientation it's uh now in the short axis uh in the um RV inflow outflow view and then in long axis in the derived sort of here uh perpendicular uh kind of uh reversed or mirror view uh tracastric view now we look at the clip and for the and we look at the position and the orientation so for this procedure we keep going constantly back and forth from tracastric short axis and RV inflow outflow view with x-plane and we can help ourselves with the fluoroscopy as you can see here to see where your probe is in respect to the clip especially for the tracastric view to align and be with your scanning plane just perfectly parallel or as parallel as possible to the clip and try to remember this picture so then if when you go back into the esophagus and then when you go back into the stomach then you remember where you are where you were and you can maybe that helps you find and sometimes when we are lost our cardiologist they just press the fluoroscopy button and then we can actually get a better picture so as we said uh uh tracastric short axis view we can see where the clip is and the orientation and the RV inflow outflow view with the derived mirror four chamber view give us a better um alignment of the clip with the scanning plane and we can see the clip arms and we will use these to uh monitor the uh how we grab the leaflet and we orient ourselves with posterior anterior uh on the left on the inflow outflow view and media lateral on the right in the four chamber view so here we come down we position the clip we close the clip we look at the leaflet the leaflet are both inside the clip with the clip is closed and here with the tracastric view you can see how the leaflet come right into the clip as I showed in this tiny little dive so we're we're pretty happy um and we look with color there's still a little bit there's still a little bit of regurgitan jet which is expected this was just one of two clips and now we come in with the second clip so you can see the first clip is to the right so closer to the arctic valve and the second clips come behind it and here on the right is the tracastric short axis view and that's where the clip is placed yeah for clip guidance then what do we use uh uh we use a a number of uh two basically two views one view is the tracastric uh midisophage tracastric short axis and the other one is midisophageal rv inflow view with the x-plane rv inflow outflow view with jacksplane unfortunately it doesn't allow us to always know exactly what leaflet we look at so on the left what we have is posterior but on the right can be septal or anterior uh our experience is as as you have this inflow outflow view then as you move towards the arctic valve you're cutting more towards the anterior leaflet then in the center and moving the probe a little bit then you cut more towards the septal leaflet but with certainty we don't that is the reason why for precise positioning of this clip we rely almost entirely on this trans gastric short axis view where we know for sure what leaflet there are and we and we can clearly position the clip and then we go back to midisophageal for the 3d helps a little bit we don't use it as much and if we want to use it then we can correlate our view with the anatomy by trying to include in your 3d block a little bit of the arctic valve and as you position the arctic valve at about 11 o'clock the arctic valve helps you identify the commissure between septal and anterior leaflet and what we often do is we take this block and we just rotate it upside down because that would allow align well with what we normally see in the trans gastric short axis view and that's what our cardiologists really like to see all the time and they help them better orient something that's a bit tricky is is decide whether we can clip or we cannot clip and we obviously always want to clip so one way to clip is if the gap between the leaflet is more than one millimeter which is which was actually remains a relative contraindication for this procedure but something that we can do is we can actually try and increase the peep and then we look at the at the same picture so this is to the left you can see or maybe you can convince yourself that if with peep there there the leaflet come a little bit close together and and this is something that usually we do when we grasp so when we actually have the clip in position and we're ready to actually grasp the leaflet we stop the ventilation we just increase the peep to 30 sometimes even 40 if the patient can tolerate it and then we stop the the ventilation for the time it takes to grasp the leaflet sometimes through three minutes the patient can tolerate if we've well if we've had them well pre-oxygenated the other trick about this procedure is that this trans gastric short axis view it's not always in the same at the same angle and sometimes it's very tricky to find and this is just an example where we were completely lost because the actually took us a while to figure out the anatomy for this patient and on the right side you can see this view we could only find it at 120 degrees so my advice is don't have a fixed number in your head but have sort of the anatomical correlation in your head and that's what you need to know you want so here is going back to our case we've deployed the second clip and regurgitant jet there's basically regurgitation the only problem was that as we look at these two clips like the one clip second clip was in was good and stable the first clip we found it was a little bit moving a little bit too much but because we couldn't get a good cut through this second clip now with multi-views we could actually get our cursor on the second on the first clip and as you can see this first clip is a little bit maybe too mobile or a little bit mobile but the leaflets are actually still going into the clip so we were sort of and we decided not to do anything a particular problem and a gradient also sort of guide for success gradient obviously we wouldn't accept anything more than three millimeters of mercury mean gradient but for the tracaspid valve it's rarely a problem so as a technical vignette and to conclude again we know a functional tracaspid regurgitation involves annular dilatation and leaflets there's been many percutaneous approaches that's been proposed then starting from addressing the annulus addressing the gap with the former device that we've had some experience in toronto before I moved here to leitzig and here with the clip we are only addressing really one problem in within these the tracaspid valve and and and so this that we actually need to know and basically all of our clinical work is based on the largest trial the one of our cardiologists philip lurtz was involved with whose senior author is rebecca han and this was the triluminate trial where 88 patients in a prospective multicenter single arm trial patients with tracaspid regurgitation there was at least moderate in a gap less than one millimeter where we're actually treated and as you as you can see although this is a little bit more it's a little bit sort of not so easy to read but there was a good success in the great majority of cases there was significant improvement of a tracaspid degree of tracaspid regurgitation and right ventricular dimensions and in terms of clinical improvement all of the patients had a significant improvement from as you can see 75 percent the baseline had either new york heart association class three or four and that actually decreased drastically at 30 days to 20 percent in a six months to 12 to 13 percent with a very low complication rate with nine percent of the patient had the tracaspid stenosis we unfortunately haven't had any so far and with the attachment of the clip from one of the leaflet in seven percent of the cases and this is something that unfortunately we've seen a few times and we've basically just dealt with like sometimes placing an extra clip or just leave it alone what is critical and what is important here and what we've learned from this from this study is that in order to have an improve in clinical outcome and the way the patient feel we don't necessarily need to resolve the tracaspid regurgitation and that's why this new classification of tracaspid regurgitation has been proposed by Rebecca and Zamorano where we have within severe we have three different levels of severity of how severe they are so severe massive and torrential where actually if we have an improvement from any of these points to the lowest one so say from torrential to massive or massive from severe at the end of the procedure the patient would still have severe tracaspid regurgitation but they will actually definitely get a significant clinical benefit and they will eventually better I remain available for any question per email I thank you once again and I'm sorry I couldn't connect live and it's a honor and I'm extremely proud to see how some of my younger colleagues have been taking this conference to the next level and they are doing phenomenal phenomenal job at Toronto General Hospital and contributing to the world of perioperative transophageal ecocardiography thank you very much